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 B
Explanation
Choice A rationale
Using antibacterial soap for general handwashing is a good hygiene practice but does not directly prevent tick bites. Tick prevention focuses on avoiding tick-infested areas and creating a barrier against ticks.
Choice B rationale
Wearing long sleeves and pants outdoors, especially in wooded or grassy areas where ticks are commonly found, is a crucial measure for preventing tick bites. This creates a physical barrier that reduces the skin's exposure to ticks.
Choice C rationale
While avoiding wooded areas can reduce the risk of tick exposure, it may not always be practical or possible. Emphasizing protective clothing and other preventive measures allows children to engage in outdoor activities while minimizing risk.
Choice D rationale
Applying sunscreen protects against sunburn but does not prevent tick bites. While important for overall skin health, sunscreen does not deter or kill ticks. Insect repellents containing DEET or picaridin are effective against ticks. .
Correct Answer is A
Explanation
Choice A rationale
For a withdrawn 4-year-old, activities that allow for self-expression and communication are beneficial. Coloring provides a non-verbal outlet for emotions, and talking about feelings, facilitated by the nurse, can help the child process their experience and reduce feelings of isolation.
Choice B rationale
Practicing reading skills is developmentally appropriate for some 4-year-olds but may not be engaging or therapeutic for a child who is currently withdrawn and emotionally distressed due to hospitalization. The focus should be on emotional expression rather than academic tasks.
Choice C rationale
Watching cartoons alone can increase feelings of isolation and does not encourage interaction or emotional expression, which are crucial for a withdrawn child in a hospital setting.
Choice D rationale
While rest is important, frequent napping can further isolate the child and may not address the underlying emotional needs contributing to their withdrawal. Encouraging active engagement and interaction is more therapeutic.
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