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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Saying, "It is not your fault that this happened," is correct. This statement reassures the child that they are not to blame for the abuse, which is crucial in reducing feelings of guilt or self-blame. It also helps build trust between the child and the nurse.

B. Saying, "This should not have happened to you," is incorrect. While it acknowledges the wrongdoing, it does not directly reassure the child that they are not responsible for the situation.

C. Saying, "I promise I won’t tell anyone about this," is incorrect and unethical. Healthcare professionals are mandated reporters and must report suspected abuse to the appropriate authorities. Making such a promise could lead to broken trust when the nurse is required to disclose the information.

D. Saying, "You should have told someone about this sooner," is incorrect. This statement may make the child feel guilty or ashamed for not speaking up earlier, which can discourage further disclosure and hinder emotional healing.

A. Mix the medication in a bottle of formula. B. Mix the medication with a small amount of honey. C. Place the medication in the back of the infant's throat using a dropper. D. Place the medication in a oral syringe.

Correct Answer is D

Explanation

A. Mix the medication in a bottle of formula is incorrect. Mixing medication in a bottle of formula may cause the infant to not receive the full dose of the medication if they do not finish the bottle. It also creates the risk of the infant associating the medication with the feeding, which could lead to future feeding issues.

B. Mix the medication with a small amount of honey is incorrect. Honey should not be given to infants under 1 year of age due to the risk of botulism. Additionally, mixing medication with any substance should be avoided unless directed by the provider.

C. Place the medication in the back of the infant's throat using a dropper is incorrect. Administering medication in the back of the throat with a dropper can be dangerous and may lead to choking. The medication should be given in a controlled manner.

D. Place the medication in an oral syringe is correct. An oral syringe is the safest method for administering medication to an infant. It allows the nurse to measure the dose accurately and administer the medication slowly to ensure it is swallowed safely.

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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?

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