A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

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.

A. Polyuria (excessive urination) is not a symptom of hypoglycemia; it is more commonly associated with hyperglycemia (high blood sugar).

B. Deep rapid respirations are more characteristic of diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes that leads to high blood sugar levels and metabolic acidosis.

C. Dry, flushed skin is not a typical symptom of hypoglycemia; it might be associated with conditions like dehydration or heat exposure, but not with low blood sugar.

D. Tachycardia

Explanation: The symptoms described by the adolescent (feeling shaky, difficulty speaking, difficulty concentrating) along with a blood glucose level of 55 mg/dL indicate hypoglycemia, which is low blood sugar. Tachycardia, or a rapid heart rate, is a common physiological response to hypoglycemia. The body increases the heart rate in an attempt to improve blood flow and deliver glucose to the brain and other vital organs. This is part of the body's fight-or-flight response to low blood sugar.