The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which of the item(s) need to be placed at the child bedside?

Tracheotomy set

Emergency cart

Padded tongue blade

Suctioning equipment and oxygen

Answer and Explanation

The Correct Answer is D

D. Suctioning equipment and oxygen are essential items to have at the bedside for seizure precautions. Seizures can sometimes be associated with airway compromise, excessive secretions, or respiratory distress. Having suctioning equipment readily available allows for prompt removal of oral or airway secretions if necessary. Oxygen may be needed to support oxygenation during or after a seizure, especially if there are concerns about respiratory depression or hypoxemia.

A. A tracheotomy set is not typically needed at the bedside for seizure precautions. Tracheotomy sets are used in emergency situations to establish a surgical airway if there is a severe airway obstruction or respiratory distress.

B. An emergency cart contains essential supplies and medications needed for emergency situations, including resuscitation equipment, medications, and supplies for managing various medical emergencies. However, the cart is not placed bedside.

C. A padded tongue blade is not typically needed at the bedside for seizure precautions. Tongue blades are sometimes used during airway management to help visualize and manipulate the tongue, but padded tongue blades are not routinely included in seizure precautions.

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Correct Answer is B

Explanation

B. Reye's syndrome is characterized by swelling of the brain (cerebral edema), which can lead to increased intracranial pressure (ICP). Monitoring for signs of increased ICP, such as changes in level of consciousness, headache, vomiting, and altered pupil size and reactivity, is crucial for early detection and intervention to prevent neurological deterioration.

A. Reye's syndrome primarily affects the liver and brain, leading to liver dysfunction and encephalopathy. While renal involvement can occur in some cases, the priority complication typically relates to liver dysfunction and neurological manifestations rather than renal impairment.

C. Hyperglycemia may be present due to liver dysfunction and altered glucose metabolism, but it is not the primary concern compared to neurological complications and hepatic failure.

D. Reye's syndrome is not caused by a bacterial infection; it is typically associated with viral illnesses, particularly influenza and varicella (chickenpox).

A. "Put an ice pack on the ankle, alternating 20 minutes on with 20 minutes off." B. "Wrap the ankle in an Ace bandage for support." C. "Keep the leg elevated when sitting" D. "Apply warm compresses to the ankle for the first 24 hours."

Correct Answer is D

Explanation

D. Warm compresses or heat therapy are not recommended for the initial management of a sprained ankle, especially within the first 24 hours. Heat can increase blood flow and exacerbate swelling and inflammation, which may worsen pain and delay healing.

A. Applying ice packs in this manner helps reduce inflammation and swelling, which are common after a sprain. Alternating ice application with periods of rest allows for effective cooling without causing tissue damage.

B. Wrapping the ankle in an Ace bandage can provide compression and support, which may help reduce swelling and stabilize the joint during the healing process. However, it's important not to wrap the bandage too tightly, as this can impair circulation.

C. Elevating the leg when sitting helps reduce swelling by promoting venous return and preventing fluid accumulation in the injured area. Keeping the ankle elevated above the level of the heart whenever possible is recommended for optimal swelling reduction.

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The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which of the item(s) need to be placed at the child bedside?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse reviews the plan of care for a child with Reye's syndrome. The nurse plans to monitor for which priority complication of this syndrome?

Correct Answer is B

Explanation

The nurse is providing instructions about how to treat a sprained ankle. What statement by the mother does the nurse recognize as indicative of a need for additional teaching?

Correct Answer is D

Explanation

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