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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An increase in potassium levels is not directly related to the effectiveness of furosemide, which is a diuretic and can actually cause hypokalemia.
B. A decrease in edema indicates that the diuretic is effectively removing excess fluid from the body, which is a desired effect of furosemide in treating heart failure.
C. An increase in respiratory rate could indicate worsening heart failure or fluid overload, not the effectiveness of the medication.
D. A decrease in appetite is not a specific indication of the effectiveness of furosemide.
Correct Answer is A
Explanation
A.Infants with HF tire easily; feeding them early, before they are overly fatigued and crying, conserves energy and helps them take in more nutrition. Smaller, more frequent feedings are often recommended.
B. A firm nipple may require more effort to suck, which can be tiring for an infant with heart failure. A softer nipple may be more appropriate.
C. Diluting the formula with water can lead to inadequate caloric intake and nutritional deficiencies. Formula should be prepared according to instructions to ensure proper nutrition.
D. Thickened feeds are sometimes used for reflux, not HF. Adding cereal increases caloric intake but also makes sucking/swallowing more difficult, increasing energy expenditure.
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