A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic clonic seizure.The mother is hysterical and is trying to hold the child down.

Which action(s) should the nurse take? Select all that apply.

A. Place pillows inside the side rails.

Place pillows inside the side rails.

Ask the mother to release the child.

Administer an anticonvulsant medication.

Close the blinds to darken the room.

Monitor the child's airway and tongue.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale

While placing pillows inside the side rails can prevent injury, it may not be effective if the child is having a severe tonic-clonic seizure, as the child could still injure themselves. Padding the entire bed with approved padding is more appropriate in such a case.

Choice B rationale

During a seizure, it is crucial to ensure the child’s safety by asking the mother to release the child to prevent unintentional injury. Holding the child down during a seizure can cause harm to both the child and the mother, and it's important to provide a safe space for the child to move.

Choice C rationale

Administering an anticonvulsant medication can help control the seizure and prevent further convulsions. Medications such as benzodiazepines are often used to treat ongoing seizures and can provide rapid relief.

Choice D rationale

Closing the blinds to darken the room is not directly beneficial during a seizure and does not address the immediate need to protect the child from injury or manage the seizure effectively. While reducing light may help in other conditions, it is not a priority during a seizure.

Choice E rationale

Monitoring the child's airway and tongue is critical to ensure they are not at risk of choking or aspiration during a seizure. Keeping the airway clear and observing for any obstructions can prevent further complications and ensure the child’s safety.

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Correct Answer is A

Explanation

Choice A rationale

Non-nutritive sucking, such as with a pacifier, can be soothing and calming for infants. It helps in the development of oral motor skills and provides comfort during enteral feedings, ensuring that the infant’s need for sucking is met even when they are not feeding.

Choice B rationale

Sterile technique is essential for preventing infections during invasive procedures, but enteral feeding typically does not require such stringent measures. Clean technique is usually sufficient unless the infant has a compromised immune system or other specific medical conditions requiring sterile precautions.

Choice C rationale

While verifying tube placement is critical, it is often done using methods such as pH testing of gastric contents or external marking rather than routine x-rays. Overuse of x-rays exposes infants to unnecessary radiation. X-rays are used primarily when other methods are inconclusive.

Choice D rationale

Instituting physical therapy for a one-month-old infant would not be developmentally appropriate as their primary needs are centered around nutrition, comfort, and growth. Physical therapy is more relevant for older children with developmental or mobility issues rather than infants receiving enteral feedings. .

A. Detection of early symptoms of Jarisch-Herxheimer reaction. B. Collection of serial anaerobic cultures of vaginal discharge. C. Administration of a supervised parenteral antibiotic protocol. D. Implementation of contact precautions to prevent spread of infection.

Correct Answer is C

Explanation

Choice A rationale

Jarisch-Herxheimer reaction is seen in spirochete infections like syphilis or Lyme disease, not typically in pelvic inflammatory disease (PID) treated with antibiotics like levofloxacin and metronidazole.

Choice B rationale

Serial anaerobic cultures are not routine for PID management. Diagnosis and management focus more on clinical symptoms and empirical antibiotic therapy rather than continuous culture monitoring.

Choice C rationale

Supervised parenteral antibiotic protocols ensure proper dosage and administration, crucial for severe infections requiring hospitalization. Monitoring treatment in a controlled environment increases effectiveness and reduces complications.

Choice D rationale

While infection control is important, PID typically spreads through sexual contact, and hospital admission for infection control is not the primary reason. The focus is more on effective treatment delivery in severe cases. .

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A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic clonic seizure.The mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? Select all that apply. A. Place pillows inside the side rails.

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Naxlex Comprehensive Predictor Exams

A one-month-old infant admitted to the hospital with dehydration and failure to thrive receives a prescription for enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic clonic seizure.The mother is hysterical and is trying to hold the child down.

Which action(s) should the nurse take? Select all that apply.

A. Place pillows inside the side rails.