A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder.
The nurse should teach the parents to take which of the following actions during a seizure?
Insert a tongue blade between the teeth.
Place the child in a prone position.
Clear the area of hard objects.
Minimize movement of the limbs.
The Correct Answer is C
Choice A rationale:
Inserting a tongue blade between the teeth during a seizure is not recommended. Doing so can cause injury to the child's mouth or teeth. It's essential to keep the child's mouth open to prevent choking, but using a tongue blade is not the appropriate method.
Choice B rationale:
Placing the child in a prone position (face down) during a seizure can obstruct the airway and lead to difficulty breathing. It's crucial to maintain an open airway during a seizure. The correct position is to place the child on their side (recovery position) to prevent choking and ensure proper breathing.
Choice C rationale:
Clearing the area of hard objects is the correct action during a seizure. Seizures can involve uncontrolled movements, and clearing the surrounding area of any hard or sharp objects can prevent injuries. Creating a safe environment is essential to minimize the risk of harm during a seizure.
Choice D rationale:
Minimizing movement of the limbs is not entirely accurate. While it's essential to prevent injury during a seizure, attempting to restrict the child's movements forcefully can lead to injuries or fractures. The focus should be on creating a safe environment and ensuring the child is placed in a recovery position to prevent choking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice Arationale:
A temperature of 37.2°C (99°F) is slightly elevated but not a contraindication for the MMR vaccine. Low-grade fever is a common side effect of vaccines and is not a reason to withhold vaccination. The nurse should advise the parents to consult with the healthcare provider if the child has a moderate to high fever.
Choice Brationale:
Family history of seizures is not a contraindication for the MMR vaccine. The MMR vaccine is safe for individuals with a family history of seizures. However, if the child has a personal history of seizures, especially related to fever (febrile seizures), the healthcare provider should be consulted before vaccination.
Choice C rationale:
An upper respiratory infection 2 days ago is not a contraindication for the MMR vaccine. Minor illnesses without fever or systemic symptoms are not reasons to postpone routine vaccinations. The child should receive the vaccine as scheduled.
Choice D rationale:
Allergy to neomycin is the correct choice. Neomycin is an antibiotic that is sometimes present in vaccines, including the MMR vaccine. Individuals with a known allergy to neomycin should not receive vaccines containing this substance due to the risk of an allergic reaction. It is essential to screen for allergies to vaccine components to ensure the child's safety during vaccination.
Correct Answer is C
Explanation
The correct answer is Choice C. Hyporeflexia.
Choice A rationale:
Oliguria, or reduced urine output, can be associated with dehydration or renal impairment, but it is not directly related to hypokalemia (low potassium levels). Hypokalemia primarily affects the muscles and heart rather than urine output.
Choice B rationale:
Hypertension is typically associated with high blood pressure and can be seen in conditions like hyperaldosteronism or Cushing's syndrome. However, it is not a direct result of hypokalemia. Low potassium levels usually lead to other cardiovascular issues such as arrhythmias, but not hypertension.
Choice C rationale:
Hyporeflexia, or decreased reflexes, is a common sign of hypokalemia. Potassium is essential for proper nerve and muscle function. When potassium levels are low, nerve impulses are slowed, leading to diminished reflexes. This symptom aligns with the preschooler's potassium level of 3.2 mEq/L, which is below the normal range.
Choice D rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, low potassium levels can lead to a reduction in gastrointestinal motility, potentially causing constipation or decreased bowel sounds, rather than hyperactivity.
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