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 B
Explanation
Rationale:
A. This is not a common adverse effect associated with morphine.
B. Nausea is a common adverse effect of morphine and should be monitored for, particularly in pediatric patients.
C. Stevens-Johnson syndrome is a severe allergic reaction and is not typically associated with morphine.
D. While morphine can cause urinary retention, it is not typically associated with renal failure.
Correct Answer is B
Explanation
Rationale:
A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
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