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: Obtaining written consent from the client is appropriate as adolescents are entitled to confidential care for STIs. This respects the client's autonomy and privacy.
Choice B reason: Contacting the client's parents may not be necessary unless the adolescent is under the age specified by law for independent consent. It could also breach confidentiality.
Choice C reason: Postponing the testing could delay diagnosis and treatment, which is not in the best interest of the client. Immediate testing is important for health and well-being.
Choice D reason: Requesting verbal consent from the social worker is not appropriate as the consent should come directly from the client or their legal guardian, if required.
Correct Answer is D
Explanation
Choice Areason: Decreased urine output is not directly related to ventriculoperitoneal shunt displacement. It may indicate other issues such as dehydration or kidney problems.
Choice Breason: Increased sleeping is not a specific indicator of shunt displacement. While it may be a concern if there are significant changes in the child's sleep patterns, it is not a definitive sign of this complication.Choice C reason: Hyperactive bowel sounds are not associated with shunt displacement. They may indicate gastrointestinal issues but are not relevant to the function of a ventriculoperitoneal shunt.
Choice D reason: An elevated temperature can be an indicator of shunt displacement, as it may suggest an infection or other complications related to the shunt. Parents should be aware of this sign and seek medical attention if it occurs.
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