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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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale

The conjunctivae, the mucous membranes that cover the front of the eye and line the inside of the eyelids, can show signs of cyanosis. However, they are not the most reliable indicator of central cyanosis. Central cyanosis is best observed in areas with a rich blood supply and thin skin, where the bluish discoloration due to low oxygen levels in the blood is more apparent.

Choice B rationale

The soles of the feet are not a reliable indicator of central cyanosis. Peripheral cyanosis, which affects the extremities, can occur due to poor circulation or cold temperatures and does not necessarily indicate central cyanosis. Central cyanosis is more accurately assessed in areas with a high concentration of blood vessels and thin skin.

Choice C rationale

The oral mucosa, including the lips and tongue, is the most reliable indicator of central cyanosis. This area has a rich blood supply and thin skin, making it easier to observe the bluish discoloration caused by low oxygen levels in the blood. Central cyanosis is a sign of significant hypoxemia and requires prompt medical attention.

Choice D rationale

The ear lobes are not the most reliable indicator of central cyanosis. While they can show signs of cyanosis, they are not as accurate as the oral mucosa. The ear lobes may be affected by peripheral cyanosis, which can occur due to factors like cold temperatures or poor circulation, rather than central cyanosis.

A. Tugging on the affected ear lobe. B. Erythema and edema of the affected ear. C. Pain when manipulating the affected ear lobe. D. Clear drainage from the affected ear.

Correct Answer is A

Explanation

The correct answer is A. Tugging on the affected ear lobe.

Choice A rationale

Tugging on the affected ear lobe is a common sign of otitis media in children. This behavior is often observed because the child is experiencing discomfort or pain in the ear, and tugging or pulling on the ear lobe is a way to express or alleviate that discomfort.

Choice B rationale

Erythema and edema of the affected ear are not typical findings in otitis media. These symptoms are more commonly associated with external ear infections, such as otitis externa.

Choice C rationale

Pain when manipulating the affected ear lobe is more indicative of otitis externa rather than otitis media. Otitis media involves the middle ear, and manipulation of the ear lobe does not typically cause pain.

Choice D rationale

Clear drainage from the affected ear is not a typical finding in otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a more severe infection or a ruptured eardrum.

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