The nurse is called to the patient's room by the patient's spouse when the patient experiences a seizure. Upon finding the patient in a clonic reaction, the nurse should:
1.Turn the patient to the side.
2.Start oxygen by mask at 6 L/min.
3.Restrain the patient's arms and legs to prevent injury.
4.Record the time sequence of the patient's movements and responses as they occur
Rationale: During the seizure, the nurse should maintain a patent airway, protect the patient's head, turn the patient to the side, loosen constrictive clothing, and ease the patient to the floor, if seated. The patient should not be restrained, and no objects should be placed in the mouth. After the seizure, the patient may require repositioning to open and maintain the airway, suctioning, and oxygen. When a seizure occurs, the nurse should carefully observe and record details of the event because diagnosis and subsequent treatment often rest solely on the seizure description.