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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 A

Explanation

The correct answer is Choice A.

Choice A rationale

Encouraging the parents to rock the infant provides comfort and emotional support, which is crucial for the infant’s recovery. Rocking can also help soothe the infant and promote bonding between the parents and the child.

Choice B rationale

Administering ibuprofen as needed for pain is not recommended for infants under 6 months of age due to the risk of adverse effects such as gastrointestinal bleeding and kidney damage.

Choice C rationale

Positioning the infant on her abdomen is contraindicated after cleft lip repair surgery as it can put pressure on the surgical site, potentially causing damage and increasing the risk of infection.

Choice D rationale

Offering the infant a pacifier is not advisable as sucking can put strain on the surgical site, potentially leading to complications and delaying the healing process.

A. Explains the difference between right and wrong. B. Prints letters and numbers. C. Cooperates in doing simple chores. D. Separates easily from primary caregiver for short periods of time.

Correct Answer is D

Explanation

The correct answer is D. Separates easily from primary caregiver for short periods of time.

Choice A rationale

Explaining the difference between right and wrong is a developmental task expected of older children, typically preschoolers or early school-aged children. Toddlers are still developing their understanding of rules and consequences.

Choice B rationale

Printing letters and numbers is a skill expected of preschoolers or early school-aged children. Toddlers are still developing fine motor skills and are not yet capable of printing letters and numbers.

Choice C rationale

Cooperating in doing simple chores is a developmental task that can be expected of toddlers. However, it is not as specific or significant as the ability to separate easily from the primary caregiver for short periods of time, which is a key developmental milestone for toddlers.

Choice D rationale

Separating easily from the primary caregiver for short periods of time is an important developmental milestone for toddlers. It indicates that the child is developing a sense of independence and trust in their environment, which is crucial for their social and emotional development.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is D

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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.)