A client with a history of epilepsy arrives in the emergency departmen

A client with a history of epilepsy arrives in the emergency department experiencing status epi-lepticus. The nurse should never do which of the following?

1. Document sequence of events, including any adverse outcomes.
2. Prepare to initiate IV access.
3. Access oxygen and suctioning equipment.
4. Open client’s mouth by placing fingers on jaw and inserting thumb on bottom teeth to place oral airway between seizures.

ANSWER

ANS: 4
Nurses should never put their fingers in or close to a clients mouth who is or has been experienc-ing seizure activity, to prevent being bitten in the event that the client should experience more seizure activity. The nurse is responsible for all of these measures in Answers 1, 2, and 3 to pro-vide for the safety of the client, as well as document the sequence of events including any unex-pected outcomes.