A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure.

Which of the following actions should the nurse take?

Oﬀer the child sips of clear ﬂuids.

Place the child in a supine position.

Administer an oral antiepileptic medication.

Check the child for oral injuries.

Answer and Explanation

The Correct Answer is D

After a tonic-clonic seizure, the nurse should first check the child for any injuries, particularly in the oral cavity. This is because during a seizure, the child's tongue may have been biten, or there may be other oral injuries. Therefore, it is essential to check the oral cavity for any injury or bleeding.

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Correct Answer is B

Explanation

It is important to provide choices for the client, but limit them to two or three options to prevent confusion and decision-making difficulties.

Use visual cues to assist the client with locating the bathroom, such as pictures or color-coded signs instead of written signs.

Avoid using confrontation to manage the client's behavior, as it can increase agitation and aggression. Instead, use redirection and positive reinforcement.

Provide a calm and non-stimulating environment for the client, as overstimulation can lead to confusion and agitation.

A. Assist the client to the orthopneic position. B. Instruct the client to remain as still as possible during the recording. C. Attach a blood pressure cuff to the client's upper arm. D. Tell the client to expect a mild stinging sensation during the test.

Correct Answer is B

Explanation

It is important for the client to remain still during the recording of a 12-lead ECG to obtain accurate and clear readings of the heart's electrical activity.

The orthopneic position (sitting upright and leaning forward) is typically used to help relieve shortness of breath in clients with respiratory distress and is not directly related to obtaining a 12-lead ECG.

Attaching a blood pressure cuff is not necessary for obtaining a 12-lead ECG, as it measures blood pressure and not the electrical activity of the heart.

A mild stinging sensation is not expected during the test. The electrodes used to record the ECG are typically adhesive and do not cause discomfort to the client

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A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure.

Which of the following actions should the nurse take?