A child is experiencing a tonic-clonic seizure. Which nursing action is most appropriate during the seizure?
Turn the child to the side to prevent aspiration.
Give an oral benzodiazepine medication to stop the seizure.
Insert a tongue blade to prevent airway obstruction.
Restrain the child to minimize injury.
The Correct Answer is A
Choice A rationale
During a tonic-clonic seizure, loss of consciousness and uncontrolled muscle movements carry a high risk of aspiration if the child vomits or has excessive oral secretions. Turning the child to the side (recovery position) allows gravity to drain secretions and prevents the tongue from obstructing the posterior pharynx, which is the most critical immediate safety intervention.
Choice B rationale
While benzodiazepines (like rectal or intranasal diazepam or midazolam) are used to stop seizures, this is done via a non-oral route as the child is typically unconscious and unable to safely swallow during a seizure, posing a severe aspiration risk. Oral administration is contraindicated during the acute seizure event itself.
Choice C rationale
Inserting a tongue blade or any object into the mouth during a seizure is strictly contraindicated. The child's jaw may clamp down forcefully, causing injury to the child's teeth, gums, or jaw, or causing the object to break and obstruct the airway, leading to far more harm than benefit.
Choice D rationale
Restraining the child during a seizure is inappropriate and dangerous. The forceful muscle contractions can cause injury (fractures or dislocations) if movement is restricted against the convulsive forces. The nurse's role is to clear the area and protect the head and limbs from striking hard objects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An oxygen saturation SpO_2 of 88% indicates significant hypoxemia (low blood oxygen), which is the most critical physiological derangement in respiratory distress. Sustained hypoxemia can rapidly lead to cerebral hypoxia, increasing intracranial pressure, and cardiac arrest, necessitating immediate intervention. Normal is ≥ 94-95% in most children.
Choice B rationale
A heart rate of 160 beats per minute in a school-age child (6-12 years) is tachycardia (normal is 75-115 bpm), often an initial compensatory response to hypoxemia and increased work of breathing. While concerning, it is an attempt to maintain cardiac output, making the SpO_2 decline a more immediate life threat.
Choice C rationale
A temperature of 100.4°F is a low-grade fever, which can increase metabolic demand and O_2 consumption, potentially worsening respiratory status. While it warrants management, it is not the most immediate life-threatening sign compared to severe hypoxemia (SpO_2 of 88%). Normal is 97.7°F to 99.5°F.
Choice D rationale
A respiratory rate of 40 breaths per minute in a toddler (1-3 years) is near the upper limit of normal (25-35 bpm) and indicates tachypnea, a compensatory mechanism to improve gas exchange. While significant, it is a sign of compensation, whereas the low SpO_2 suggests decompensation.
Correct Answer is B
Explanation
Choice A rationale
Kawasaki disease (KD) is an acute systemic vasculitis often leading to an inflammatory state characterized by fever, conjunctivitis, and rash. The child is expected to be tachycardic and often hypertensive (due to inflammation and hyperdynamic state), or may be hypotensive in later shock, but bradycardia and hypotension are not typical diagnostic findings in the acute phase.
Choice B rationale
The presence of strawberry tongue (erythema and prominent papillae) and peeling (desquamation) of the palms and soles (especially in the subacute phase) are two of the key mucocutaneous findings that fulfill the American Heart Association's diagnostic criteria for Kawasaki disease. This systemic inflammatory response targets epithelial and vascular tissues.
Choice C rationale
Petechiae, small pinpoint hemorrhages, are often associated with conditions like meningococcemia, septicemia, or platelet disorders such as Idiopathic Thrombocytopenic Purpura (ITP). While a non-specific maculopapular rash or perineal desquamation can occur in Kawasaki disease (KD), petechiae are not considered a classic or defining diagnostic criterion.
Choice D rationale
Splinter hemorrhages are small lines of blood under the fingernails or toenails, classically associated with infective endocarditis (microemboli lodging in the nail bed capillaries). While Kawasaki disease can lead to carditis, splinter hemorrhages are not a specific assessment finding that supports the initial diagnosis of this particular systemic vasculitis.
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