A home health nurse is providing teaching about postseizure 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,E
A. "Hyperextend your child's head for 5 minutes following a seizure."
This instruction is incorrect. Hyperextending the head after a seizure is not recommended and could potentially cause harm. Instead, it's important to ensure that the child's airway is clear and maintain a safe and comfortable position.
B. "Immediately following a seizure, give your child 6 ounces of water."
This instruction is not necessary unless the child specifically requests water or appears to be dehydrated. It's important to focus on ensuring the child's safety and comfort immediately after a seizure.
C. "Following a seizure, record the length and characteristics of your child's seizure."
This instruction is correct. Keeping a record of the length and characteristics of the child's seizures can provide valuable information to healthcare providers for managing the child's epilepsy and adjusting treatment as needed.
D. "Administer rectal diazepam to your child following a seizure."
This instruction may be appropriate in some cases, particularly if the child's seizures are prolonged or if they have a history of status epilepticus. However, the administration of rectal diazepam should be done according to the healthcare provider's instructions and with proper training.
E. "Call for emergency medical services if the size of your child's pupils are unequal after a seizure."
This instruction is correct. Unequal pupil size (anisocoria) after a seizure could indicate a serious underlying condition and should prompt immediate medical evaluation. It's important for the parents to be aware of this potential sign of concern and to seek prompt medical attention if it occurs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Droplet:
Pertussis is primarily transmitted through respiratory droplets when an infected person coughs or sneezes. Droplet precautions involve placing the child in a private room or with another child with the same infection. Healthcare workers should wear a mask or respirator when entering the room to protect against droplet transmission.
B. Contact:
Contact precautions are used for infections that can be spread by direct or indirect contact with the patient or their environment. Pertussis is not typically spread through contact with contaminated surfaces or objects.
C. Airborne:
Airborne precautions are used for infections that are transmitted through small droplet nuclei that remain in the air for long periods. Pertussis is primarily transmitted through larger respiratory droplets rather than tiny airborne particles.
D. Protective environment:
Protective environment precautions are used for patients who have weakened immune systems, such as those undergoing bone marrow transplants. These precautions are not applicable for a child with pertussis.
Correct Answer is D
Explanation
A. Temperature of 38°C (100.4°F):A mild fever is not a contraindication for the MMR vaccine. In fact, a low-grade fever is common after immunizations and does not warrant withholding the vaccine.
B. Family history of sudden unexpected infant death (SUID): While a family history of SUID may be concerning, it is not a contraindication for administering the MMR vaccine. This history would not directly impact the safety or effectiveness of the vaccine.
C. Taking an antihistamine for seasonal allergies: Taking an antihistamine for seasonal allergies does not typically contraindicate the administration of the MMR vaccine. Antihistamines are generally safe to use with vaccines, and they do not interfere with the immune response to the vaccine.
D. Receiving prednisone for nephrotic syndrome:Prednisone is an immunosuppressive medication. Children receiving high-dose corticosteroids (such as prednisone) should avoid live vaccines like MMR
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