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

Collecting a urine sample to screen for protein is essential as proteinuria is a key indicator of preeclampsia, a condition characterized by high blood pressure and potential organ damage during pregnancy. Early detection is vital to manage the condition and prevent complications.

Choice B rationale

Asking about a history of delivering large babies (macrosomia) is not immediately relevant to the current symptoms of headache and elevated blood pressure, which are more indicative of hypertensive disorders rather than previous birth weights.

Choice C rationale

Examining the client for pedal edema is important but not the immediate priority. While edema can be associated with preeclampsia, the presence of proteinuria and elevated blood pressure are more critical indicators that need to be addressed first.

Choice D rationale

Establishing the frequency of headaches is useful information but not the immediate priority. The combination of an excruciating headache and elevated blood pressure necessitates a more urgent assessment for preeclampsia, starting with a urine sample for protein.

A. Projectile vomiting. B. Arched back. C. Frequent pauses. D. Coffee-ground emesis.

Correct Answer is A

Explanation

Choice A rationale

Projectile vomiting in an infant with an olive-like mass in the abdomen suggests pyloric stenosis. This condition causes severe vomiting due to gastric obstruction. It's a hallmark symptom and requires monitoring and surgical intervention.

Choice B rationale

While arching the back can occur in various conditions, it is not specifically indicative of pyloric stenosis. It could be a sign of discomfort or other neurological issues but not directly related to the gastrointestinal obstruction seen in pyloric stenosis.

Choice C rationale

Frequent pauses during feeding are common in many infant conditions and are not specific to pyloric stenosis. They indicate general feeding difficulties but are not diagnostic of this particular condition.

Choice D rationale

Coffee-ground emesis indicates bleeding in the gastrointestinal tract but is not typical of pyloric stenosis. The hallmark sign is non-bloody, forceful vomiting due to gastric outlet obstruction.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

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.