A nurse is caring for a school-age child who is having a tonic-clonic seizure. Which of the following actions should the nurse take?
Administer chlorothiazide.
Hold the child down.
Place the child in a prone position.
Time the episode.
The Correct Answer is D
Rationale:
A. Chlorothiazide is a diuretic and is not indicated during a seizure.
B. Holding the child down during a seizure can lead to injury and is not recommended. It's essential to ensure the child's safety by protecting the head from injury and removing any objects that could cause harm.
C. Placing the child in a prone position during a seizure can compromise their ability to breathe and is not recommended. Instead, the child should be placed in a safe position on their side to prevent aspiration.
D. Timing the duration of the seizure is crucial for medical management and documentation purposes. This action allows healthcare providers to assess the
severity of the seizure and determine the need for intervention or medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. In many jurisdictions, adolescents have the legal right to consent to testing and treatment for sexually transmitted infections (STIs) without parental involvement. Obtaining written consent from the client is appropriate in this situation.
B. While verbal consent from the social worker may be helpful, the client's own consent is required for STI testing.
C. Depending on local laws and policies, contacting the client's parents for consent may not be necessary or appropriate, especially if the adolescent is seeking confidential care.
D. Postponing testing until the client's parents are present may delay necessary medical care and breach the adolescent's right to confidential healthcare.
Correct Answer is D
Explanation
Rationale:
A. Obtaining an x-ray of the child's neck may be necessary for diagnosis, but ensuring immediate safety and infection control measures take precedence.
B. Administering intravenous antibiotics is important in the treatment of epiglottitis but is not the immediate priority.
C. Initiating droplet precautions is crucial in this case to prevent the spread of infection to others but is not as important as securing the airway.
D. Placing intubation equipment at the bedside is the first priority because epiglottitis can cause airway obstruction and respiratory distress.
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