In the context of stress physiology, when a nurse is in a client's room and the client begins having a tonic-clonic seizure, what is the nurse's immediate priority action?

• A. Attempt to restrain the client's movements to prevent harm
• B. Protect the client from injury by clearing the area and cushioning the head
• C. Insert an oral airway to prevent tongue biting
• D. Leave the room to call for help immediately

Answer: (B)

Verified step by step guidance

1. Step 1: Understand the physiological context of a tonic-clonic seizure, which involves involuntary muscle contractions and loss of consciousness, making the client vulnerable to injury.
2. Step 2: Recognize that the nurse's immediate priority is to ensure the client's safety by preventing physical harm during the seizure.
3. Step 3: Identify actions that protect the client, such as clearing the surrounding area of dangerous objects and cushioning the client's head to prevent injury.
4. Step 4: Understand why other actions, like restraining movements or inserting an oral airway, are not immediate priorities or may cause harm during the seizure.
5. Step 5: Conclude that the nurse should stay with the client, protect them from injury, and call for help if needed, rather than leaving the room immediately.