A nurse is caring for a child during a tonic-clonic seizure. Which of the following actions should the nurse take? (Select all that apply)
Loosen tight clothing around the child's neck.
Firmly hold the child's arms to one side.
Place a pillow under the child's head.
Insert a tongue blade into the child's mouth.
Clear the area of hard objects.
Correct Answer : A,C,E
Choice A reason: Loosening tight clothing around the child's neck is important to ensure that the child can breathe easily and to prevent any additional discomfort or injury during the seizure.
Choice B reason: It is not recommended to firmly hold the child's arms to one side as this can cause injury. Instead, the nurse should ensure the child's safety by clearing the area of any hard or sharp objects.
Choice C reason: Placing a pillow under the child's head can help to protect the head from injury during the seizure. It provides a soft cushion to prevent the child from hitting their head on hard surfaces.
Choice D reason: Inserting a tongue blade into the child's mouth is not advised as it can cause injury to the child's mouth or teeth, and there is a risk of the child biting down and breaking the blade.
Choice E reason: Clearing the area of hard objects is crucial to prevent injury to the child during the seizure. Removing any potential hazards ensures a safer environment for the child to move without harm.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Slurred speech may indicate a stroke or other neurological complication, which is a medical emergency. Sickle cell anemia can lead to such complications, and immediate assessment is crucial.
Choice B reason: While a partial-thickness burn requires care, it is not as immediately life-threatening as potential neurological complications. The toddler should be assessed after more urgent cases.
Choice C reason: A pain level of 7 is significant, but pain management can be addressed after more critical needs are met. The adolescent's pain should be managed effectively once urgent cases are stabilized.
Choice D reason: Administering an IV bolus of nafcillin for osteomyelitis is important, but it does not take precedence over potential neurological issues. The toddler should receive the medication promptly after urgent assessments.
Correct Answer is D
Explanation
Choice A reason: While exposure to secondhand smoke is unhealthy and should be avoided, it is not commonly listed as a trigger for seizures. The primary concern with secondhand smoke is its impact on respiratory health.
Choice Breason: A prolonged headache can be a symptom of various conditions, but it is not generally considered a direct trigger for seizures. However, if a headache is related to a neurological condition, it may be associated with an increased risk of seizures.
Choice Creason: Decreased temperature, or being cold, is not typically a trigger for seizures. Seizure triggers are usually related to changes in the body's internal environment or external stimuli that affect the nervous system.
Choice D reason: Inadequate sleep is a well-known trigger for seizures. Sleep deprivation can lead to increased seizure activity in individuals with seizure disorders. Ensuring adequate and regular sleep is an important part of managing seizure disorders.
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