A patient begins having a generalised tonic-clonic seizure while sitting in a chair. What should the nurse do first?
Correct answer: A. Protect the patient from injury and lower them safely
- A. Protect the patient from injury and lower them safely
- B. Insert a padded tongue blade between the teeth
- C. Restrain the arms and legs to stop the movements
- D. Give oral water when the movements begin to slow
Explanation
The immediate priority during a seizure is preventing injury while maintaining airway safety. The nurse should ease the patient to the floor, protect the head, remove nearby hazards, and observe the seizure. Nothing should be placed in the mouth, and restraints are unsafe.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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