A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)
Loosen restrictive clothing.
Hyperextend the child's neck.
Time the seizure episode.
Place the child in a side-lying position.
Restrain the child.
Correct Answer : A,C,D
Rationale:
A) Loosening restrictive clothing prevents injury during the seizure.
B) Hyperextending the child's neck can cause injury and should be avoided. Instead, the neck should be supported to maintain an open airway.
C) Timing the seizure episode is important for documenting the duration and for providing accurate information to healthcare providers.
D) Placing the child in a side-lying position helps prevent aspiration and maintains an open airway during the seizure.
E) Restraint should not be applied during a seizure unless absolutely necessary to prevent injury to the child or others.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A) Pertussis is spread via respiratory droplets, so droplet precautions should be initiated.
B) Contact precautions are used for diseases transmitted by direct contact with the patient or their environment, not for pertussis.
C) Airborne precautions are used for diseases transmitted by airborne particles, such as tuberculosis or measles, not for pertussis.
D) Protective precautions are not a standard precaution type; they involve protecting immunocompromised patients from acquiring infections.
Correct Answer is C
Explanation
Rationale:
A. While spinal fluid analysis may be necessary in some cases, it is not typically used to confirm a diagnosis of acute lymphoid leukemia (ALL).
B. A complete blood count (CBC) may show abnormalities suggestive of leukemia, but it is not definitive for diagnosis.
C. Bone marrow biopsy is necessary to confirm the diagnosis of acute lymphoid leukemia (ALL) by examining the bone marrow for abnormal cells.
D. Bleeding time is not typically used to diagnose acute lymphoid leukemia (ALL); it assesses platelet function.
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