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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Correct Answer is C
Explanation
Choice A reason: Hypothermia is not a common finding associated with inhalation of gasoline. It typically occurs due to exposure to cold temperatures and is not related to chemical inhalation.
Choice B reason: Hyperactive reflexes are not typically associated with gasoline inhalation. They can be a sign of neurological disorders or a response to certain medications, but not commonly from inhalants.
Choice C reason: Mydriasis, which is the dilation of the pupils, can occur with inhalation of gasoline due to its effect on the nervous system. It is a sign that the nurse should be aware of during the assessment.
Choice D reason: Pinpoint pupils are more commonly associated with opioid overdose and not with inhalation of gasoline. The nurse should expect to see dilated pupils rather than constricted ones.
Correct Answer is A
Explanation
Choice A reason: A gluten-free diet is essential for managing celiac disease, as gluten can trigger harmful immune responses in affected individuals. This diet excludes all forms of wheat, barley, rye, and oats unless they are labeled gluten-free.
Choice B reason: A high-fiber diet is generally healthy but is not specifically related to the management of celiac disease. During exacerbations, it is more important to ensure that all foods are gluten-free to avoid triggering symptoms.
Choice C reason: There is no need for a low-protein diet in celiac disease management. Protein is not related to the immune response triggered by gluten.
Choice D reason: Wheat flour contains gluten and must be avoided in a gluten-free diet. Alternative flours such as rice, corn, or gluten-free blends should be used instead.
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