RN Nursing · Neurological Disorders in Children · Practice question
The nurse observes a child in the hospital suddenly drop their toy, fall to the ground, and begin making repetitive, uncontrolled movements with their arms and legs. The child's jaw is clenched, and they are unresponsive to verbal commands. Which action should the nurse take?
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Attempt to restrain the child's movements to minimize muscle strain.
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✓
Ensure a clear area around the child to prevent injury.
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Elevate the child's head and place a pillow under their neck.
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Open the child's mouth and insert a padded tongue blade.
Answer & explanation
Correct: Ensure a clear area around the child to prevent injury.
The child is experiencing a tonic-clonic seizure, characterized by falling, repetitive uncontrolled limb movements, jaw clenching, and unresponsiveness. The priority nursing action during a seizure is protecting the child from injury by ensuring the surrounding area is clear of hard or sharp objects. This prevents the child from striking furniture or equipment during the convulsive movements. Attempting to restrain the child's movements is dangerous and contraindicated; forcible restraint can cause fractures, joint injuries, or dislocations. Elevating the head and placing a pillow under the neck is inappropriate during active seizure activity; the head should be turned to the side to protect the airway from aspiration, and a flat surface is safer. Inserting any object into a clenched mouth is a classic and serious error — it can break teeth, injure the jaw, and cause the nurse to be bitten; nothing should ever be placed in the mouth of a seizing patient. After the seizure ends, the nurse should position the child in the recovery position, time the seizure, assess responsiveness, administer any prescribed anti-epileptic medications, and notify the provider if the seizure is prolonged or a first-time event.
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