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.)
Place a tongue depressor in the client's mouth.
Restrain the client.
Assess the client's airway palenty
Remove objects from the client's bed
Place the client in a side-lying position
Correct Answer : C,D,E
A) Place a tongue depressor in the client's mouth:
Incorrect. Placing a tongue depressor in the client's mouth is not recommended during a seizure. Doing so can lead to injury, as the child may bite down on the depressor and cause harm to their teeth or mouth.
B) Restrain the client:
Incorrect. Restraining a person during a seizure can be extremely dangerous. It can lead to physical harm to both the person experiencing the seizure and the person trying to restrain them. Restraining can increase the risk of fractures, dislocations, and other injuries.
C) Assess the client's airway patency:
Correct. Assessing the client's airway patency is essential during a seizure. The nurse should ensure that the child's airway is clear and open to maintain proper breathing. This involves observing for any obstruction or difficulty in breathing and taking appropriate measures to keep the airway open.
D) Remove objects from the client's bed:
Correct. Removing objects from the client's bed is a necessary action to prevent injury during a seizure. Objects on the bed can pose a risk of harm to the child if they were to strike them during the seizure. Creating a safe environment by removing potential hazards is important.
E) Place the client in a side-lying position:
Correct. Placing the client in a side-lying position is recommended during a seizure. This position helps prevent aspiration and maintains a clear airway. It also reduces the risk of choking and allows any fluids to drain from the mouth, minimizing the risk of choking.
In summary:
Choice A is incorrect because placing a tongue depressor can cause injury.
Choice B is incorrect because restraining can lead to harm.
Choice C is correct because assessing the airway ensures proper breathing.
Choice D is correct because removing objects reduces the risk of injury.
Choice E is correct because placing the client in a side-lying position helps maintain a clear airway and prevents aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Heat intolerance.
Explanation: This statement is true. Heat intolerance is a common symptom of hyperthyroidism, including Graves' disease. People with hyperthyroidism often have an overactive thyroid gland that produces an excessive amount of thyroid hormones. This can lead to an increased metabolic rate, which in turn makes them sensitive to heat. They may feel excessively warm, sweat more than usual, and have difficulty tolerating hot weather.
B) Weight gain.
Explanation: This statement is false. Weight gain is not a typical finding in Graves' disease or hyperthyroidism. In fact, one of the hallmark symptoms of hyperthyroidism is unexplained weight loss despite increased appetite. The elevated levels of thyroid hormones cause an increase in metabolism, leading to weight loss.
C) Bradycardia.
Explanation: This statement is false. Bradycardia refers to an abnormally slow heart rate, typically below 60 beats per minute. In hyperthyroidism, the heart rate is often elevated rather than slowed down. The excessive thyroid hormones can lead to an increased heart rate (tachycardia) and palpitations. It's important to note that if the question were about hypothyroidism (underactive thyroid), bradycardia might be more relevant.
D) Lethargy.
Explanation: This statement is false. Lethargy, or a state of extreme tiredness and lack of energy, is more commonly associated with hypothyroidism (underactive thyroid) rather than hyperthyroidism. Hyperthyroidism usually leads to symptoms of increased energy, restlessness, and hyperactivity due to the elevated metabolic rate caused by excess thyroid hormones.
Correct Answer is C
Explanation
A) "Limit fluid intake during mealtime":
Limiting fluid intake during meals is not a standard practice for managing type 1 diabetes. Proper hydration is important for overall health, and fluids should be consumed as needed.
B) "Notify the provider if blood glucose levels are over 350 milligrams/deciliter":
Blood glucose levels over 350 mg/dL can indicate hyperglycemia, which requires prompt attention. High blood glucose levels can lead to complications if not addressed promptly. Contacting the healthcare provider is an appropriate step. However, consistentBlood Glucose Levels Above 240 mg/dL (13.3 mmol/L) or presence of symptoms likefrequent urination, thirst, blurry vision, or fatigue) are concerning. The clientshould have contacted the health care provider by this point.
C) "Test the urine for ketones":
Testing urine for ketones is an important instruction. Ketones are produced when the body breaks down fat for energy, often in the absence of sufficient insulin. High ketone levels can indicate diabetic ketoacidosis (DKA), a serious complication. Regular ketone testing, especially during illness or high blood glucose levels, helps monitor for DKA.
D) "Withhold insulin dose if feeling nauseous":
This instruction is not accurate. Nausea could be a sign of various conditions, including illness. Insulin should not be withheld without consulting a healthcare provider. Managing insulin doses appropriately is crucial to maintaining blood glucose control
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