A charge nurse is supervising a newly licensed nurse who is caring for a client who is experiencing auditory hallucinations and is refusing medication. The newly licensed nurse suggests placing the medication in the client's food to the charge nurse. Which of the following actions should the charge nurse take?

Suggest the family persuade the client to take the medication.

Recommend that the medication be delivered intramuscularly.

Remind the newly licensed nurse that the client has a right to refuse medication.

Suggest the newly licensed nurse contact the pharmacy to inquire about compatible foods.

Answer and Explanation

The Correct Answer is C

The charge nurse should remind the newly licensed nurse that the client has a right to refuse medication. It is important for healthcare providers to respect the autonomy and rights of their clients, including the right to refuse treatment.

Option a is incorrect because it may not be appropriate for the family to persuade the client to take medication against their wishes.

Option b is incorrect because delivering medication intramuscularly against the client's wishes would violate their right to refuse treatment.

Option d is incorrect because inquiring about compatible foods with the pharmacy would not address the issue of the client's right to refuse medication.

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Correct Answer is B

Explanation

Explanation:

The nurse should respond by recommending that the parent avoids administering aspirin to the child. The use of aspirin in children, especially those under the age of 18, is associated with the risk of developing Reye's syndrome, a rare but serious condition that aﬀects the liver and brain. It is important to educate parents about the potential risks of using aspirin in children, particularly when they have a fever. Instead, the nurse should advise the parent to use appropriate dosages of acetaminophen or ibuprofen based on the child's weight and follow the label directions for administration.

Option a suggests following the label directions based on the child's weight, which may not specifically address the use of aspirin in children and the risk of Reye's syndrome. Option c, stating that the child will require an antibiotic if she develops a fever, is incorrect because antibiotics are not indicated for all fevers and should only be prescribed if there is an underlying bacterial infection. Option d, suggesting that the child can have two baby aspirins every 4 hours, is incorrect and contradicts the recommendation to avoid administering aspirin to the child.

A. Call EMS if a seizure lasts 5 min or more. B. Restrain the child at the onset of the seizure. C. Oﬀer the child a bubble bath every evening. D. Place the child in a prone position during the seizure.

Correct Answer is A

Explanation

The correct answer is a. Call EMS if a seizure lasts 5 minutes or more.

Explanation:

When providing home care instructions for a child with a seizure disorder, it is important to educate the parents about appropriate actions during a seizure. Calling emergency medical services (EMS) if a seizure lasts 5 minutes or more is crucial because it may indicate a condition called status epilepticus, which is a prolonged seizure or a series of seizures without full recovery of consciousness between them. Status epilepticus is a medical emergency that requires immediate medical intervention.

Option b, restraining the child at the onset of a seizure, is not recommended. Restraint can potentially cause harm to the child and increase the risk of injury. It is advised to create a safe environment by removing any nearby objects that could cause injury and placing a pillow or cushion under the child's head to prevent head injury.

Option c, oﬀering the child a bubble bath every evening, is not specifically related to seizure management. Bathing routines can be continued as long as they are safe and supervised. However, it is important to ensure the child's safety during bathing, such as providing adequate supervision to prevent drowning or injury.

Option d, placing the child in a prone position during a seizure, is not recommended. Placing the child in a prone position (face down) during a seizure can obstruct the airway and increase the risk of respiratory complications. The child should be placed on their side, in a recovery position, to facilitate drainage of saliva or other ﬂuids and prevent choking.

Overall, the most important instruction for the parents is to recognize the signs of prolonged seizure activity and to seek immediate medical assistance by calling EMS if a seizure lasts 5 minutes or more.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include?

Correct Answer is A

Explanation

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