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 B
Explanation
A. Give the infant liquids using a small spoon with a long handle.
Give the infant liquids using a small spoon with a long handle.While feeding is essential, the method described is not specific to postoperative care after cleft palate repair.Feedings are resumed by bottle, breast/chest, or cup per surgeon preference; some surgeons prescribe the use of an Asepto syringe for feeding or a soft cup such as a soft-tipped sippy cup.
B. Apply elbow restraints to the infant.
Apply elbow restraints to the infant is correct.Elbow restraints would be used to prevent the infant from injuring or traumatizing the surgical site.
C. Gently check the infant's suture line using a padded tongue depressor.
It's important to assess the surgical site for signs of infection or bleeding, but using a padded tongue depressor may not be the most appropriate method. The nurse should follow the surgeon's orders regarding wound care and assessment techniques, which may include visual inspection without manipulation.
D. Place the infant in a supine position.
Placing the infant in a supine position is generally recommended after cleft palate repair surgery to minimize strain on the surgical site and promote healing. However, it's essential to ensure proper positioning to prevent aspiration and maintain airway patency.
Correct Answer is D
Explanation
A. Depressed scalp veins: This is an incorrect choice. In hydrocephalus, there is increased pressure within the skull due to the accumulation of cerebrospinal fluid (CSF). This increased pressure typically leads to distended scalp veins rather than depressed ones.
B. Sunken anterior fontanels: This is an incorrect choice. The fontanel, also known as the soft spot on an infant's head, may actually bulge rather than appear sunken in cases of hydrocephalus due to increased intracranial pressure.
C.Bulging eyes:In individuals with hydrocephalus, especially infants and young children, bulging eyes can sometimes occur.The increased pressure inside the skull can affect various structures within the brain, including the optic nerve and the muscles that control eye movement. This can lead to a condition called papilledema, where the optic nerve becomes swollen due to the pressure. Papilledema can cause changes in vision and, in some cases, contribute to the appearance of bulging eyes.
D.Separated cranial sutures:The separation of cranial sutures in hydrocephalus occurs due to the increased pressure from the excess CSF. This pressure can cause the bones of the skull to move apart, leading to visible gaps or widening of the sutures. Clinically, this can be observed through imaging studies such as CT scans or MRI.
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