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?
Minimize movement of the limbs.
Clear the area of hard objects.
Place the child in a prone position.
Insert a tongue blade between the teeth.
The Correct Answer is B
Rationale:
A. Minimizing movement of the limbs is not necessary during a seizure and can be harmful.
B. Clearing the area of hard objects helps prevent injury to the child during a seizure by reducing the risk of hitting or bumping into objects.
C. Placing the child in a prone position is not recommended during a seizure as it can obstruct the airway.
D. Inserting a tongue blade between the teeth is contraindicated and can lead to injury. It's important not to put anything in the child's mouth during a seizure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Given the cloudy appearance of the cerebrospinal fluid (CSF) and elevated white blood cell count (WBC) in the CSF, there may be an indication of meningitis.
Ceftriaxone is a broad-spectrum antibiotic commonly used to treat bacterial meningitis. Therefore, administering ceftriaxone would be an appropriate action.
B. While vaccines are important for preventing infections, administering the pneumococcal conjugate vaccine is not the immediate priority in this scenario. The patient is already exhibiting signs of a potential infection, and treatment should focus on addressing the current condition first.
C. The infant's serum glucose level is low at 64 mg/dL (normal range: 60 to 100 mg/dL).
However, the primary concern at this moment appears to be the potential bacterial meningitis indicated by the cloudy CSF, elevated WBC count, and abnormal CSF glucose level. While monitoring serum glucose is important, it is not the most critical action in this case.
D. Neutropenic precautions are typically implemented to protect patients with low neutrophil counts (neutropenia) from acquiring infections. However, there is no indication of neutropenia in the provided diagnostic results. Additionally, the cloudy CSF and elevated WBC count suggest a possible bacterial infection rather than a neutropenic condition.
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