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 D
Explanation
A. FACES: The FACES pain scale is a visual analog scale commonly used with older children who can point to or select a facial expression that best represents their pain level. It may not be suitable for infants who may not have the cognitive or motor skills to use the scale effectively.
B. COMFORT: The COMFORT scale assesses pain in infants and young children based on behaviors such as crying, facial expressions, and body movements. It evaluates parameters such as alertness, calmness, respiratory response, physical movement, and muscle tone. The COMFORT scale is suitable for assessing pain in infants and young children, including those who are postoperative.
C. CRIES: The CRIES scale is a neonatal pain assessment tool that evaluates crying, oxygen saturation, vital signs, expression, and sleeplessness. While it is designed for newborns and infants up to 6 months of age, it may not be as appropriate for a 12-month-old infant who is postoperative and beyond the neonatal period.
D. FLACC: The FLACC scale assesses pain in infants and young children based on five behavioral categories: facial expression, leg movement, activity level, cry, and consolability. It is commonly used in pediatric settings and is suitable for assessing pain in infants who are postoperative.
Correct Answer is B
Explanation
A. "Seal nonwashable items in a plastic bag for 2 days."
This instruction is incorrect. Items that cannot be laundered may be dry-cleaned or sealed in a plastic bag for two weeks
B. "Soak hair brushes in boiling water for 10 minutes."This is correct. According to CDC, combs and brushes should be soaked in hot water (at least 130 degrees fahrenheit) to help avoid re-infestation.
C. "Apply permethrin 1 percent cream rinse every day for 5 days."
This instruction is incorrect. Permethrin 1 percent cream rinse is a medication used to treat head lice infestations, but it is typically applied only once and then rinsed out after a specified period of time (usually 10 minutes). Repeated daily application for five days is not recommended and may lead to unnecessary exposure to the medication.
D. "After washing bed linens, place them in a dryer on a cool setting for 30 minutes."
This instruction is incorrect. To effectively kill lice and nits on bed linens, they should be washed in hot water (at least 130°F or 54°C) and then dried on a hot setting in the dryer. A cool setting may not be sufficient to kill lice and nits.
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