A home health nurse is providing teaching about post seizure management to the parents of a school-age child who has epilepsy and experiences tonic-clonic seizures. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)
Hyperextend your child's head for 5 minutes following a seizure."
"Immediately following a seizure, give your child 6 ounces of water."
"Following a seizure, record the length and characteristics of your child's seizure."
"Administer rectal diazepam to your child following a seizure."
"Call for emergency medical services if the size of your child's pupils are unequal after a seizure."
Correct Answer : C,D,E
A. "Hyperextend your child's head for 5 minutes following a seizure."
Hyperextension can obstruct the airway. Instead, place the child in a side-lying position to maintain an open airway.
B. "Immediately following a seizure, give your child 6 ounces of water."
Do not give anything orally until the child is fully awake and the gag reflex has returned to avoid aspiration.
C. "Following a seizure, record the length and characteristics of your child's seizure."
Important for tracking seizure activity and evaluating treatment effectiveness.
D. "Administer rectal diazepam to your child following a seizure."
Rectal diazepam may be prescribed for prolonged or clustered seizures, especially at home.
E. "Call for emergency medical services if the size of your child's pupils are unequal after a seizure."
Unequal pupils post-seizure may indicate increased intracranial pressure or brain injury and warrant immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Depressed scalp veins
Scalp veins would likely be distended or prominent due to increased intracranial pressure, not depressed.
B. Sunken anterior fontanels
The fontanelle would be bulging, not sunken, in hydrocephalus due to increased intracranial pressure.
C. Bulging eyes
Hydrocephalus does not typically cause bulging eyes. "Sunsetting eyes" (downward gaze with visible sclera above the iris) may be seen instead.
D. Separated cranial sutures
Increased intracranial pressure from excess cerebrospinal fluid (CSF) causes the sutures to separate due to skull expansion in infants.
Correct Answer is D
Explanation
A. Decreased respiratory rate:
Respiratory rate may increase due to fluid overload and acidosis, but decreased rate is not typical.
B. Polyuria:
In the initial phase of AKI, oliguria (low urine output) is common, not polyuria.
C. Hyperactivity:
Hyperactivity is unrelated to AKI; lethargy and confusion are more likely.
D. Edema:
Edema occurs due to fluid retention from decreased urine output in acute kidney injury (AKI).
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