A nurse is caring for a child who is having a seizure.
Which of the following actions should the nurse take? (Select all that apply.)
Restrain the client.
Place the client in a side-lying position.
Place a tongue depressor in the client’s mouth.
Assess the client’s airway patency.
Remove objects from the client’s bed.
Correct Answer : B,D,E
Choice A rationale
Restraining a child during a seizure is not recommended. It does not stop the seizure and can lead to injury. The child’s movements during a seizure are involuntary, so trying to stop them can cause harm.
Choice B rationale
Placing the child in a side-lying position is recommended during a seizure. This position helps to prevent aspiration, which can occur if the child vomits during the seizure.
Choice C rationale
It is a common misconception that a person having a seizure can swallow their tongue, but this is not true. Attempting to place a tongue depressor or any other object in the child’s mouth during a seizure can cause injury to the child’s teeth or jaw.
Choice D rationale
Assessing the child’s airway patency is crucial during a seizure. Seizures can cause changes in breathing patterns and can potentially lead to respiratory distress. Therefore, monitoring the child’s breathing during a seizure is important.
Choice E rationale
Removing objects from the child’s bed or surrounding area can help prevent injury during a seizure. During a seizure, the child may have uncontrolled movements, and removing nearby objects can help ensure the child’s safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Vaginal bleeding during pregnancy can be a sign of a serious complication such as placenta previa or placental abruption. Placenta previa is a condition where the placenta partially or completely covers the cervix, which can lead to severe bleeding during pregnancy and delivery. Placental abruption is a serious condition in which the placenta separates from the uterus before the baby is born, which can cause heavy bleeding and can be life-threatening for both the mother and the baby. Therefore, any vaginal bleeding during pregnancy should be promptly reported to the healthcare provider.
Choice B rationale
Lightheadedness when lying on the back, also known as supine hypotensive syndrome, can occur in pregnancy when the enlarged uterus compresses the inferior vena cava, reducing blood return to the heart and causing a drop in blood pressure. While this can be uncomfortable, it is generally not considered a serious complication and can be alleviated by changing position.
Choice C rationale
Heartburn after eating is a common discomfort during pregnancy due to hormonal changes that relax the lower esophageal sphincter, allowing stomach acid to reflux into the esophagus. While it can be uncomfortable, it is generally not a sign of a serious complication.
Choice D rationale
Swelling of the ankles, also known as edema, is common in pregnancy due to increased fluid volume in the body. While it can be uncomfortable, it is generally not a sign of a serious complication unless it is sudden or severe, which could be a sign of preeclampsia.
Correct Answer is A
Explanation
Choice A rationale
Supporting the casted arm with a firm grasp is important to prevent unnecessary movement and potential discomfort or injury to the child. It also helps in ensuring the correct positioning of the cast.
Choice B rationale
Placing a heated fan at the bedside to facilitate drying is not recommended. Excessive heat can cause discomfort and potential burns to the child. The cast should be allowed to dry naturally.
Choice C rationale
Telling the child that the cast will make their arm feel better can be misleading. While the cast is necessary for healing, it may cause discomfort and itching. It’s important to explain to the child what the cast is for and what to expect.
Choice D rationale
Wrapping the arm of the child’s doll or toy prior to the procedure can help the child understand what is happening and make them feel more comfortable. However, this action alone is not sufficient in preparing to apply a cast to a preschooler’s arm.
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