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?
Place a pillow under the child's head.
Clear the area of hazards.
Position the child side-lying
Loosen restrictive clothing
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) A step-wise approach will be used to reduce the dosage gradually.
Explanation:
After a certain period of seizure control, a healthcare provider may consider gradually tapering and discontinuing anti-seizure medications in consultation with the child's neurologist. This is often done in a step-wise manner to monitor the child's condition and minimize the risk of seizure recurrence. Stopping anti-seizure medications abruptly can increase the risk of seizures returning. Therefore, the response provided in option A is the most accurate and relevant to the situation.
The other options are incorrect:
B) Your child will always suffer seizures:
This statement is not accurate, as some children with epilepsy can achieve long-term seizure control with appropriate treatment. Epilepsy management varies from person to person, and many individuals can experience extended periods of seizure freedom.
C) This is always a hereditary disorder:
Epilepsy can have both genetic and non-genetic causes. While there are genetic forms of epilepsy, not all cases are hereditary. Epilepsy can be caused by a variety of factors, including brain injuries, infections, and other medical conditions.
D) Only her male offspring will experience seizures:
Epilepsy does not discriminate based on gender. Both males and females can be affected by epilepsy. This statement is not accurate and does not reflect the reality of epilepsy as a medical condition.
Correct Answer is C
Explanation
A. Assume you made a mistake and report out the same head circumference as before.
Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.
Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.
B. Take Vital Signs.
Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.
Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.
C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.
Correct Explanation: This is the best next step.
Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.
D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.
Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.
Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.
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