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","D","E"]
Explanation
Rationale:
A. Cyanosis can occur in children with heart failure due to inadequate oxygenation of tissues.
B. Weight gain or fluid retention is more common in children with heart failure.
C. Bounding pulses are more commonly associated with conditions such as hypertension or hyperthyroidism, rather than heart failure.
D. Dyspnea, or difficulty breathing, is a common symptom of heart failure due to fluid buildup in the lungs.
E. Tachycardia, or a rapid heart rate, can occur as a compensatory mechanism in response to decreased cardiac output in heart failure.
Correct Answer is D
Explanation
Rationale:
A. Disseminated intravascular coagulation (DIC) is associated with consumption of clotting factors, leading to prolonged clotting times, such as increased prothrombin time (PT) and activated partial thromboplastin time (aPTT), rather than decreased.
B. DIC does not typically cause an increase in hemoglobin (Hgb) levels; in fact, it may lead to anemia due to blood loss and consumption of clotting factors.
C. DIC does not typically cause an increase in red blood cell (RBC) count; if anything, it can lead to anemia due to blood loss.
D. DIC is characterized by widespread activation of coagulation, leading to consumption of platelets and decreased platelet count, which can result in bleeding tendencies.
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