During a tonic-clonic seizure, what should the nurse do first?

• A. Turn patient on their side
• B. Take a measure to prevent injury
• C. Restrain patient
• D. Pad the floor with pillow

Answer: (B)

The main idea is safety during a seizure. The first priority is to prevent injury because the person is at high risk of harming themselves from sudden, uncontrolled movements and from falling. The nurse should act to reduce this risk by clearing the surrounding area of sharp or hard objects, guiding the person to the floor if needed, and cushioning the head. Loosen restrictive clothing around the neck and avoid restraining the person or trying to forcefully stop the movements. Do not place anything in the mouth. If possible, time the seizure so you know its duration. After the convulsions stop, help the person into a side-lying position to protect the airway and assist breathing, and continue monitoring until full recovery.