A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder.
Which of the following instructions should the nurse include?
Call EMS if a seizure lasts 5 min or more.
Restrain the child at the onset of the seizure.
Offer the child a bubble bath every evening.
Place the child in a prone position during the seizure.
The Correct Answer is A
The correct answer is a. Call EMS if a seizure lasts 5 minutes or more.
Explanation:
When providing home care instructions for a child with a seizure disorder, it is important to educate the parents about appropriate actions during a seizure. Calling emergency medical services (EMS) if a seizure lasts 5 minutes or more is crucial because it may indicate a condition called status epilepticus, which is a prolonged seizure or a series of seizures without full recovery of consciousness between them. Status epilepticus is a medical emergency that requires immediate medical intervention.
Option b, restraining the child at the onset of a seizure, is not recommended. Restraint can potentially cause harm to the child and increase the risk of injury. It is advised to create a safe environment by removing any nearby objects that could cause injury and placing a pillow or cushion under the child's head to prevent head injury.
Option c, offering the child a bubble bath every evening, is not specifically related to seizure management. Bathing routines can be continued as long as they are safe and supervised. However, it is important to ensure the child's safety during bathing, such as providing adequate supervision to prevent drowning or injury.
Option d, placing the child in a prone position during a seizure, is not recommended. Placing the child in a prone position (face down) during a seizure can obstruct the airway and increase the risk of respiratory complications. The child should be placed on their side, in a recovery position, to facilitate drainage of saliva or other fluids and prevent choking.
Overall, the most important instruction for the parents is to recognize the signs of prolonged seizure activity and to seek immediate medical assistance by calling EMS if a seizure lasts 5 minutes or more.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Answer: D
Rationale:
A) Collect 2 mL of sputum in an emesis basin: Collecting sputum in an emesis basin is inappropriate for laboratory testing. The sputum should be collected directly into a sterile container to prevent contamination. This ensures that the culture and sensitivity results are accurate and reflect the client's true respiratory pathogens.
B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum sample is not recommended because it may alter the flora present in the sputum, leading to inaccurate culture results. Instead, the client should rinse their mouth with plain water to clear excess saliva or food debris.
C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx does not obtain sputum from the lungs but instead gathers a sample from the throat, which may not be reflective of lower respiratory infections. A proper sputum sample is produced through a deep cough to collect material directly from the lungs.
D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen helps to preserve its integrity by preventing the overgrowth of bacteria or other pathogens until it can be transported to the laboratory. Proper refrigeration ensures that the culture and sensitivity results remain accurate.
Correct Answer is D
Explanation
A newly licensed nurse who is having difficulty finishing client care tasks during their shift should try to complete one task before moving on to the next. This can help the nurse stay focused and organized, and prevent them from becoming overwhelmed.
The other options are not recommended for time management.
a) Delegating complicated tasks to an RNmay not be appropriate or allowed, depending on the task and the nurse's scope of practice.
b) Documenting all client care at the end of the shiftcan lead to errors and omissions.
c) Performing quick tasks before time-consuming tasks may not be the most efficient use of time, as it can lead to unfinished tasks at the end of the shift.
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