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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 pillow under the child's head.

B.

Clear the area of hazards.

C.

Position the child side-lying

D.

Loosen restrictive clothing

Answer and Explanation

The Correct Answer is C

A. Place a pillow under the child's head.

Explanation: While providing comfort is important, the priority in this scenario is to ensure the child's safety. Placing a pillow under the head can be considered after addressing immediate safety concerns.

B. Clear the area of hazards. 

Explanation: Correct Choice. Ensuring the area is clear of hazards is the nurse's priority. During a seizure, the child can experience uncontrolled movements, and having hazards around can lead to injuries. Clearing the area helps prevent harm. But priority is to position the child side lying.

C. Position the child side-lying.

Explanation: Correct Choice. Placing the child in a side-lying position helps prevent choking and aspiration due to vomiting during the seizure. It also minimizes the risk of airway obstruction and helps manage secretions. 

D. Loosen restrictive clothing.

Explanation: While loosening restrictive clothing can facilitate breathing, the priority in this situation is addressing safety concerns related to the seizure and vomiting. Ensuring a clear and safe environment takes precedence.


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Related Questions

Correct Answer is A

Explanation

A. You do not need to lose consciousness to suffer a concussion.

This statement is true. Concussion is a type of traumatic brain injury (TBI) that can occur without loss of consciousness. Many concussions happen without the person losing consciousness at all.

B. You will suffer permanent brain damage.

This statement is not necessarily true. While some concussions can lead to lasting effects, not all cases result in permanent brain damage. The severity and long-term effects of a concussion can vary widely.

C. We encourage fluids after a concussion.

This statement is true. Adequate hydration is important after a concussion. Staying hydrated can help support the brain's recovery process.

D. Bleeding always occurs with a concussion.

This statement is not true. Concussion is defined by the disruption of normal brain function due to a blow or jolt to the head or body, and bleeding is not always a necessary component of a concussion. However, more severe head injuries could involve bleeding and would not be classified as just a concussion.

Correct Answer is A

Explanation

Fluid Requirement (mL/24 hours) = Weight (kg) × Fluid Requirement (mL/kg)

Given that the child weighs 70.4 pounds, we first need to convert this weight to kilograms (1 lb = 0.453592 kg):

Weight in kg = 70.4 lb × 0.453592 kg/lb ≈ 31.89 kg

Now, let's calculate the fluid requirement using the given choices:

A) 1740:

Fluid Requirement = 31.89 kg × 55 mL/kg = 1753.95 mL

B) 134056:

This number is significantly larger than any reasonable fluid requirement and is likely an error.

C) 2:

This value is far too low to represent the fluid requirements of a child.

D) 12:

This value is also too low to represent the fluid requirements of a child.

So, the correct answer is A) 1740 mL. The child's estimated daily fluid requirement would be around 1740 mL in a 24-hour period, based on a weight of 70.4 pounds.

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