The practical nurse (PN) is caring for a child who was admited after experiencing a generalized tonic-clonic seizure. When witnessing the child begin the seizure, what should the PN implement immediately? (Select all that apply)
Observe the progression of the seizure
Hold the extremities close to the body
Insert a tongue blade between the teeth
Pad the side rails with pillows
Loosen clothing around the neck
Correct Answer : A,D,E
The correct answers are:
a) Observe the progression of the seizure.
- Pad the side rails with pillows.
- Loosen clothing around the neck.
Explanation: During a generalized tonic-clonic seizure, it is important for the practical nurse (PN) to prioritize the safety and well-being of the child. The correct actions to implement immediately are:
a) Observe the progression of the seizure: The PN should closely observe the seizure to gather important information that can be helpful for medical professionals in assessing the seizure's characteristics and duration.
- Pad the side rails with pillows: Padding the side rails of the bed with pillows helps to prevent the child
from injuring themselves by hitting the side rails during the seizure.
- Loosen clothing around the neck: Loosening any tight clothing around the child's neck helps to ensure adequate breathing and prevent any constriction or discomfort during the seizure.
- Hold the extremities close to the body: This action is not recommended during a seizure as it may increase the risk of injury to the child or the PN.
- Insert a tongue blade between the teeth: It is not recommended to insert any object, including a tongue blade, between the teeth of a person experiencing a seizure. This can cause injury to the person's mouth or teeth and is no longer considered an appropriate intervention for seizures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Ensure that the call bell is easily accessible to the client.
Choice A rationale:
Reassuring the client that someone will check on him hourly is supportive but does not directly address the immediate need for the client to call for assistance if he needs to use the bathroom during the night.
Choice B rationale:
Placing fresh water and a glass within reach is helpful for hydration but may increase the need to urinate, which could exacerbate the issue of urinary frequency at night.
Choice C rationale:
Ensuring that the call bell is easily accessible allows the client to quickly and safely request assistance if he needs to use the bathroom, reducing the risk of falls and ensuring timely help.
Choice D rationale:
Offering an evening snack before providing oral care is a good practice for comfort and nutrition but does not directly address the issue of urinary frequency or the need for nighttime assistance.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
The client will have no signs of infection in the wound by day 7. Rationale: This outcome is appropriate because it sets a specific timeframe (day 7) for assessing the absence of infection in the wound. It provides a clear and measurable criterion for evaluating the effectiveness of the wound care plan.
Choice B rationale:
The client will report a pain level of 4/10 or less during dressing changes. Rationale: Pain management is an essential aspect of wound care. Setting a target pain level (4/10 or less) during dressing changes allows for monitoring and adjustment of pain management strategies, making it an appropriate outcome.
Choice C rationale:
The client will consume at least 75% of meals and snacks daily. Rationale: While nutrition is important for wound healing, this outcome is less directly related to the wound itself. Monitoring meal consumption is a valuable goal for overall health but may not be as closely tied to wound improvement as infection control, pain management, or wound care technique.
Choice D rationale:
The client will reposition self in bed every 2 hours with assistance. Rationale: Repositioning every 2 hours is an important preventive measure for pressure ulcer development. However, this choice may not be appropriate for this particular client if they are unable to reposition themselves, even with assistance. This outcome may not be achievable for all clients, and a more individualized goal may be necessary.
Choice E rationale:
The client will demonstrate proper wound care technique before discharge. Rationale: Ensuring that the client can perform proper wound care techniques independently or with minimal assistance is a crucial outcome. This ensures that the client can maintain wound hygiene and prevent complications after discharge.
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