(Select all that apply):.
A nurse is conducting a safety assessment for a child with epilepsy.
What measures should the nurse consider implementing to prevent injury during seizures?
Remove sharp objects or hazards from the child's environment.
Administer antiepileptic medication.
Place the child in a prone position.
Ensure the child's head is protected.
Restrict the child's fluid intake.
Correct Answer : A,D
Choice A rationale:
Removing sharp objects or hazards from the child's environment is essential for preventing injury during seizures.
Seizures can lead to uncontrolled movements and may cause the child to inadvertently come into contact with hazardous objects, potentially resulting in injuries.
Removing such objects from the environment is a crucial safety measure.
Choice B rationale:
Administering antiepileptic medication is not a safety measure to prevent injury during seizures; it is a part of the child's long-term management plan.
Antiepileptic medications are prescribed to help control and reduce the frequency and severity of seizures but do not address immediate safety concerns during a seizure.
Choice C rationale:
Placing the child in a prone position is not a safe practice during a seizure.
The recommended position during a seizure is the recovery position, which helps maintain an open airway and prevents aspiration.
Placing the child in a prone position can increase the risk of airway obstruction and should be avoided.
Choice D rationale:
Ensuring the child's head is protected is a crucial safety measure during seizures.
Head injuries are a common risk during seizures due to the uncontrolled movements and thrashing that may occur.
Protecting the head with padding or by placing a soft object underneath can reduce the risk of head injuries.
Choice E rationale:
Restricting the child's fluid intake is not a typical safety measure during seizures.
Dehydration can be a concern, and it's important to maintain the child's hydration status, especially if there are any concerns related to antiepileptic medications or other medical conditions.
Restricting fluids can lead to potential health risks and is not a recommended safety measure during seizures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse should collect information about the frequency and duration of the child's seizures as it is directly related to the child's condition and will help in planning the care and management of the child's epilepsy.
This information is essential for determining the severity and impact of the seizures on the child's daily life, and it will guide the healthcare team in making informed decisions about treatment and interventions.
The frequency and duration of seizures can vary among individuals, and it's important to have accurate data to tailor the care plan to the child's specific needs.
Choice B rationale:
The child's genetic test results are not directly relevant to the nurse's assessment of the child's seizure episodes.
While genetics can play a role in epilepsy, the immediate concern for the nurse is gathering information about the seizures' frequency and duration, as this will inform the care provided to the child.
Choice C rationale:
The child's blood pressure during seizures, although it may be monitored during a seizure, is not the primary information the nurse needs to collect as part of the assessment.
Seizures can cause changes in blood pressure, but this parameter is not the main focus when assessing the child's seizure episodes.
Choice D rationale:
While the family's support system is important, it is not the primary information the nurse should gather when assessing the child's seizure episodes.
The focus should be on the specific details of the seizures to ensure appropriate management and care for the child.
Correct Answer is A
Explanation
Choice A rationale:
Generalized tonic-clonic seizures are characterized by tonic (stiffening) and clonic (jerking) phases.
During the clonic phase, the child may exhibit jerking movements, and this is a typical motor symptom of this type of seizure.
Choice B rationale:
Visual hallucinations are not typically associated with generalized tonic-clonic seizures.
They are more commonly seen in other types of seizures or neurological conditions.
Choice C rationale:
Aggressive behavior is not a specific motor symptom of generalized tonic-clonic seizures.
Seizures can cause altered consciousness and bizarre or unusual behaviors, but aggression is not a hallmark of this seizure type.
Choice D rationale:
Difficulties in learning are not a motor symptom of generalized tonic-clonic seizures.
However, individuals with epilepsy may experience cognitive and learning difficulties as a result of their condition, but these difficulties are not direct motor symptoms of the seizures.
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