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?
Place a folded blanket under the child's head.
Put a tongue blade between the child's teeth.
Administer magnesium sulfate IM to the child.
Prevent movement of the child's extremities.
The Correct Answer is A
A. Placing a folded blanket or any soft object under the child's head helps to protect the head from injury during the seizure. Ensuring safety is a priority during a seizure.
B. Putting a tongue blade or any object between the child's teeth can cause injury to the child. It is no longer recommended to place anything in the mouth during a seizure.
C. Magnesium sulfate is not indicated for treating tonic-clonic seizures. The focus should be on maintaining safety and monitoring the seizure.
D. Preventing movement of the child's extremities can cause injury. Instead, the nurse should protect the child from harm and ensure the environment is safe.
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Related Questions
Correct Answer is B
Explanation
A. Fiber intake should be maintained or increased to prevent constipation due to immobility.
B. Protective padding at the pin sites helps prevent infection and irritation.
C. Traction weights should never be lifted or removed unless ordered by a physician as it can disrupt alignment.
D. Passive range-of-motion exercises are important but should be performed on the unaffected extremity. Active or passive movement of the affected extremity should be done according to medical orders.
Correct Answer is ["A","B","D"]
Explanation
A. Covering the scale with a clean sheet of paper is unnecessary and does not affect the accuracy of the weight or length measurement.
B. Measuring the infant's length from the crown of the head to the heels of the feet is the correct method for obtaining length measurements in infants.
C. Placing a stadiometer on the top of the infant's head is incorrect; the measurement should be taken from head to heel.
D. Ensuring the scale is balanced to "0" before weighing the infant is essential for obtaining an accurate weight measurement.
E. Obtaining the infant's weight with their diaper on may add unnecessary weight, potentially affecting the accuracy of the weight measurement.
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