A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Turn the child onto their back.

Restrain the child's upper extremities.

Place a padded tongue blade in the child's mouth.

Place a pillow under the child's head.

Answer and Explanation

The Correct Answer is D

The correct action to take in this situation is to place a pillow or cushion under the child's head.

This will help protect the child from injuring their head during the seizure.

It is important not to turn the child onto their back during a seizure, as this can obstruct the airway and potentially lead to respiratory distress.

Restraining the child's upper extremities is also not recommended, as it can cause injury to the child or the person trying to restrain them.

Placing a padded tongue blade or any object in the child's mouth is no longer recommended during a seizure. Doing so can cause injury to the child's mouth or teeth and is not necessary for seizure management.

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Correct Answer is C

Explanation

Roasted Salmon

The nurse should include roasted salmon on the tray for the client who follows a kosher diet.

Kosher dietary laws prohibit the consumption of shellfish such as clams and shrimp, as well as pork products like pulled pork sandwiches. Roasted salmon, on the other hand, is a permissible food item in a kosher diet.

It's important for the nurse to be aware of the client's dietary restrictions and preferences to ensure that they receive appropriate and culturally sensitive care.

A. Complete an incident report. B. Notify the client's provider. C. Document the fall in the client's medical record. D. Measure the client's vital signs.

Correct Answer is D

Explanation

The first action the nurse should take in this situation is to assess the client's condition for any injuries or signs of distress. Therefore, the nurse should measure the client's vital signs to determine if there are any immediate concerns such as hypotension or tachycardia. After ensuring the client's safety and addressing any immediate needs, the nurse should complete an incident report and document the fall in the client's medical record. The provider may also need to be notified depending on the severity of the fall and any resulting injuries.

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A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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