A 6-year-old child with a history of epilepsy is admitted to the pediatric unit following a breakthrough generalized tonic-clonic seizure at home.
Which interventions should the nurse implement to ensure the child's safety? (Select all that apply.)
Ensure suction equipment is readily available at the bedside.
Instruct the child to remain in bed at all times.
Pad the side rails of the child's bed.
Educate the parents on how to administer rectal diazepam if a seizure occurs at home.
Place the child in a supine position during sleep.
Correct Answer : A,C,D
Choice A rationale
Ensuring suction equipment is readily available is crucial for a child with a history of seizures because they are at an increased risk of aspiration during or immediately following a seizure. Suctioning helps to clear the airway of saliva, vomitus, or other secretions, preventing respiratory complications.
Choice C rationale
Padding the side rails of the child's bed provides a protective barrier against injury during a seizure. Tonic-clonic seizures involve sudden, uncontrolled muscle contractions that can cause the child to hit the side rails, potentially leading to bruising or more serious injuries. Padding helps to cushion these impacts.
Choice D rationale
Educating parents on how to administer rectal diazepam for breakthrough seizures at home empowers them to manage prolonged or clustered seizures promptly. Rectal diazepam is a benzodiazepine medication that can effectively stop a seizure, reducing the risk of status epilepticus, a medical emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
A first-degree burn involves only the epidermis, the outermost layer of the skin. It is characterized by redness (erythema), pain, and dryness, without the formation of blisters. The superficial damage affects the outer layer of epithelial cells, causing vasodilation and inflammation, leading to the observed redness and discomfort.
Choice B rationale
A second-degree burn involves the epidermis and a portion of the dermis, the layer beneath the epidermis. These burns are characterized by blisters, significant pain, redness, and swelling. The damage extends deeper into the skin, affecting nerve endings and blood vessels, leading to fluid leakage and blister formation.
Choice C rationale
A third-degree burn involves the destruction of the epidermis and the entire dermis, potentially extending into the subcutaneous tissue. These burns appear white or charred, are often painless initially due to nerve damage, and lack blisters. The full thickness destruction of skin layers impairs sensation and requires significant medical intervention, often including skin grafting.
Choice D rationale
Full-thickness burn is another term for a third-degree burn, indicating that all layers of the skin have been destroyed. This type of burn extends through the epidermis and dermis and may involve underlying subcutaneous tissue, muscle, or bone. The appearance is typically dry, leathery, and may be white, charred, or waxy.
Correct Answer is B
Explanation
Choice A rationale
Preschoolers (ages 3-5 years) are at risk for drowning, often due to their increasing independence and exploration without fully understanding water hazards. However, they are generally more coordinated than toddlers and may have some understanding of safety rules.
Choice B rationale
Toddlers (ages 1-3 years) are at the greatest risk for drowning due to their natural curiosity, developing mobility, and lack of awareness of danger. They can wander off and fall into pools, bathtubs, or even buckets of water. Their head-to-body ratio makes it difficult for them to lift their heads if they fall face-first into water.
Choice C rationale
Infants (under 1 year) are dependent on caregivers and are typically supervised closely around water. While they can drown in shallow water, their lack of mobility reduces their risk compared to toddlers who are actively exploring their environment.
Choice D rationale
Teenagers, while still at risk for drowning, often due to risk-taking behaviors around water or substance use, generally have a better understanding of water safety than younger children and are more physically capable in the water.
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