The nurse has reviewed the Provider Prescriptions at 1030, the Nurses' Notes at 1045 and 1100, and the Vital Signs at 1100.
Which of the following actions should the nurse take? Select all that apply.
Roll adolescent onto their side.
Do not restrain the adolescent.
Begin chest compressions.
Prepare to give phenytoin PO stat.
Suction the oral cavity.
Insert bite block.
Correct Answer : A,B,E
A. Rolling the adolescent onto their side is appropriate during seizure activity or altered consciousness to maintain an open airway and allow secretions or emesis to drain, reducing the risk of aspiration. This is part of standard seizure precaution care.
B. Not restraining the adolescent prevents musculoskeletal injury and does not interfere with involuntary seizure movements. Restraints can cause fractures, dislocations, or soft tissue injury and should be avoided during seizure activity.
C. Beginning chest compressions is not indicated, as the adolescent still has vital signs, a pulse, and spontaneous respirations. CPR would only be initiated if there was a confirmed absence of breathing and pulse.
D. Preparing to give phenytoin PO stat is not appropriate because the adolescent is NPO and at risk for aspiration. If anticonvulsants are required, the IV route would be used instead of oral administration.
E. Suctioning the oral cavity is appropriate to maintain airway patency and clear secretions that may accumulate during seizure activity or when the client is drowsy and unable to handle secretions effectively.
F. Inserting a bite block is unsafe during seizures, as it can break teeth, injure the mouth, or obstruct the airway. Nothing should be placed in the mouth once a seizure has started.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Indicate on a stuffed animal where the procedure will be performed: This approach is more appropriate for preschool-aged children, who learn best through play and concrete objects. School-age children benefit more from factual, age-appropriate explanations.
B. Use simple diagrams to explain the procedure: School-age children can understand basic anatomy and processes. Simple diagrams provide visual reinforcement, reduce anxiety, and help the child grasp what will happen during surgery.
C. Discuss the benefits of the procedure: While explaining benefits is important, focusing only on outcomes without addressing the child’s need for concrete understanding may not fully reduce preoperative anxiety.
D. Provide teaching immediately before the procedure: Teaching should occur in advance to give the child time to process the information, ask questions, and mentally prepare. Immediate pre-op teaching is too rushed for effective learning.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
• Keep adolescent flat in bed for 24 hr post lumbar puncture: Extended flat bed rest is not recommended after lumbar puncture, as it does not prevent spinal headache and can increase discomfort. Instead, the adolescent may be kept supine only briefly for observation.
• Place the adolescent on a cooling blanket: While the adolescent has a fever of 39° C (102.2° F), a cooling blanket can cause the body to shiver, which can increase metabolic rate and raise the core temperature. A safer method is the administration of antipyretic medications like acetaminophen.
• Administer IV acyclovir: IV acyclovir is indicated for viral meningitis, particularly caused by herpes simplex virus. This adolescent’s presentation, CSF findings (low glucose, high protein, high WBC), and purpuric rash point toward bacterial meningitis, not viral etiology, making acyclovir inappropriate here.
• Place the adolescent on seizure precautions: The adolescent has developed seizure activity with tonic-clonic features, cyanosis, and pooling secretions. Seizure precautions are essential to protect from aspiration and injury, with measures such as padded side rails, suction readiness, and airway support.
• Administer IV cefotaxime: Cefotaxime is a broad-spectrum antibiotic effective against common bacterial meningitis pathogens. Given the cloudy CSF, elevated WBC, low glucose, and rapid deterioration, immediate administration of IV antibiotics is the standard, lifesaving intervention.
• Insert a peripheral IV catheter: IV access is necessary to administer fluids, antibiotics, and emergency medications. The adolescent is also showing signs of sepsis and hypotension (BP 88/50 mmHg), so fluid resuscitation and supportive therapy via IV are vital.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.