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 C
Explanation
Rationale:
A) Peanut butter is not a rapidly absorbed source of glucose and may not be appropriate for treating hypoglycemia.
B) While rechecking the child's blood glucose level is important, immediate treatment should be initiated for symptomatic hypoglycemia.
C) Administering a rapidly absorbed source of sugar, such as 1 tablespoon of sugar or honey, is the priority intervention for treating hypoglycemia in a conscious child.
D) Documenting the incident is important but should not delay the administration of treatment for hypoglycemia.
Correct Answer is C
Explanation
Rationale:
A) Inability to hold a bottle is typically achieved by 4-6 months, so it might indicate a developmental delay.
B) Palmar grasp is a primitive reflex typically seen in newborns, and it should be replaced by more voluntary grasping patterns by 8 months.
C) Sitting unsupported is a milestone typically achieved by 6-8 months, indicating expected growth and development at 8 months.
D) Forcing the tongue outward when touched might indicate tongue thrust reflex, which should typically disappear around 4-6 months.
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