A nurse is caring for a school-age child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
Prevent movement of the child's extremities.
Administer magnesium sulfate to the child.
Put a tongue blade between the child's teeth.
Place a folded blanket under the child's head.
The Correct Answer is D
A. Prevent movement of the child's extremities is incorrect. Attempting to prevent movement during a tonic-clonic seizure is unsafe. The nurse should avoid restraining the child, as this can cause injury. The focus should be on ensuring safety during the seizure.
B. Administer magnesium sulfate to the child is incorrect. Magnesium sulfate is used for certain conditions, such as preeclampsia in pregnant women or seizures due to eclampsia, but it is not typically used to manage tonic-clonic seizures in children. Anticonvulsant medications or emergency interventions are more appropriate.
C. Put a tongue blade between the child's teeth is incorrect. Inserting a tongue blade or any object into the mouth during a seizure is dangerous, as it can lead to injury to the mouth, teeth, or airway. The nurse should not attempt to put anything in the child's mouth.
D. Place a folded blanket under the child's head is correct. The priority during a tonic-clonic seizure is to protect the child from injury. Placing a folded blanket or soft padding under the head helps prevent head trauma if the child falls to the ground during the seizure. The nurse should also ensure the environment is clear of sharp objects.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Pain following range-of-motion exercises is incorrect. Mild discomfort during movement can be expected in a healing fracture. However, severe pain unrelieved by medication or worsening pain should be reported as it could indicate compartment syndrome.
B. Coolness of the toes is correct. Cool or pale toes may indicate compromised circulation, which is a sign of compartment syndrome or impaired perfusion. This is a medical emergency and should be reported immediately.
C. Pruritus under the cast is incorrect. Itching is a common, non-emergent issue with casts and can be managed with safe interventions such as blowing cool air inside the cast. However, inserting objects to scratch the skin should be avoided.
D. Presence of swelling while the extremity is dependent is incorrect. Some degree of swelling is expected when the limb is in a dependent position. Elevating the extremity can help reduce swelling, but persistent swelling with other signs of neurovascular compromise should be reported.
Correct Answer is B
Explanation
A. Offering one banana and 1/2 cup of rice with each meal is incorrect. Although bananas and rice are part of the BRAT diet, which is sometimes recommended for diarrhea, the primary concern in mild dehydration is restoring fluids first. Once hydration is managed, a regular diet can be resumed.
B. Giving 2 tsp of oral rehydration solution every 5 to 10 minutes is correct. Small, frequent amounts of oral rehydration solution (ORS) help replace lost fluids without overwhelming the stomach, reducing the risk of further vomiting or diarrhea. ORS is the preferred treatment for mild dehydration.
C. Encouraging intake of fruit juices is incorrect. Fruit juices, especially apple or pear juice, contain high amounts of sugar, which can worsen diarrhea by drawing water into the intestines and increasing stool output. Instead, ORS should be used to rehydrate the child.
D. Administering promethazine as needed is incorrect. Promethazine is an antiemetic that is not typically recommended for children due to the risk of sedation and potential side effects. Additionally, vomiting is not the primary symptom of E. coli infections, so rehydration should be the main focus.
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