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.
Assess the client’s airway patency.
Remove objects from the client’s bed.
Place the client in a side-lying position.
Place a tongue depressor in the client’s mouth.
Correct Answer : B,C,D
The correct answers are B. Assess the client’s airway patency,
C. Remove objects from the client’s bed, and D. Place the client in a side-lying position.
Choice A rationale
Restraining the client during a seizure is not recommended as it can cause injury. The focus should be on ensuring the client’s safety and preventing harm.
Choice B rationale
Assessing the client’s airway patency is crucial during a seizure to ensure that the client is breathing properly and that the airway is not obstructed.
Choice C rationale
Removing objects from the client’s bed helps prevent injury during a seizure. Objects in the bed can pose a risk of harm if the client hits them during the seizure.
Choice D rationale
Placing the client in a side-lying position helps maintain an open airway and reduces the risk of aspiration. This position allows any secretions to drain out of the mouth, preventing choking.
Choice E rationale
Placing a tongue depressor in the client’s mouth is not recommended and can cause injury. It is a common misconception that this prevents the client from swallowing their tongue, but it can actually cause more harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice B rationale
Administering an intravenous antibiotic is the priority action for a child with suspected bacterial meningitis. Early administration of antibiotics is crucial to treat the infection and prevent complications such as brain swelling and seizures.
Choice A rationale
Obtaining blood cultures is important for identifying the causative organism, but it should be done immediately before or concurrently with the administration of antibiotics.
Choice C rationale
Preparing the child for a lumbar puncture is necessary for diagnosing meningitis, but it should not delay the administration of antibiotics.
Choice D rationale
Placing the child in isolation is important to prevent the spread of infection, but it is not the immediate priority over administering antibiotics.
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Budesonide via dry-powder inhaler is a corticosteroid used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
Choice B rationale
Cromolyn via metered-dose inhaler is a mast cell stabilizer used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations.
Choice C rationale
Albuterol via jet nebulizer is a short-acting beta-adrenergic agonist that provides rapid bronchodilation. It is the medication of choice for immediate relief of acute asthma exacerbations.
Choice D rationale
Montelukast orally is a leukotriene receptor antagonist used for long-term control of asthma. It is not effective for immediate relief of acute asthma exacerbations. .
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