What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?

Guide the child to the floor if the child is standing, and then go for help.

Move objects out of the child’s immediate area.

Stick a padded tongue blade between the child’s teeth.

Manually restrain the child.

Answer and Explanation

The Correct Answer is B

Choice A reason: Guiding a child to the floor during a seizure is unsafe, as it risks injury to both the child and nurse due to uncontrolled movements. Leaving to get help abandons the child, increasing injury risk during the seizure’s tonic-clonic phase.
Choice B reason: Moving objects away from a child during a tonic-clonic seizure prevents injury from striking hard surfaces. Generalized seizures cause uncontrolled muscle contractions, increasing the risk of trauma. Ensuring a safe environment is a priority to minimize harm during the seizure event.
Choice C reason: Inserting a tongue blade, even padded, risks dental injury or airway obstruction, as jaw clenching is common in tonic-clonic seizures. Current guidelines advise against placing objects in the mouth, as it does not prevent tongue biting and may cause harm.
Choice D reason: Restraining a child during a seizure can cause fractures or soft tissue injury due to forceful muscle contractions. It also increases stress and hypoxia risk. Allowing the seizure to occur while ensuring safety is the recommended approach to minimize complications.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Anorexia is not a hallmark late sign of RA. It may occur early due to systemic inflammation but is less specific in late stages, where joint damage and systemic complications like Felty syndrome dominate.
Choice B reason: Felty syndrome, a late RA complication, involves neutropenia, splenomegaly, and recurrent infections due to chronic immune activation. It occurs in long-standing RA, reflecting severe disease progression, making it a key late finding.
Choice C reason: Joint deformity (e.g., swan-neck, boutonniere) is a classic late RA sign due to chronic synovial inflammation eroding cartilage and bone, causing joint instability and deformation, significantly impacting function in advanced disease.
Choice D reason: Low-grade fever is an early RA symptom due to systemic inflammation but typically diminishes in late stages. Chronic joint damage and systemic complications are more prominent, making fever less characteristic of late RA.
Choice E reason: Weight loss is a late RA sign due to chronic inflammation, increased metabolic demand, and cytokine activity (e.g., TNF-alpha). It reflects disease severity and systemic impact, common in advanced RA with joint destruction.

A. The seizure lasts more than 5 minutes. B. The child is sleepy and lethargic after the seizure. C. The child fell at the onset of the seizure. D. The child is confused and has slurred speech after the seizure.

Correct Answer is A

Explanation

Choice A reason: A seizure lasting over 5 minutes is considered status epilepticus, a medical emergency requiring immediate intervention to prevent brain hypoxia or injury. Prolonged seizures increase glutamate release, causing excitotoxicity, neuronal damage, and systemic complications like respiratory failure, necessitating urgent 911 response.
Choice B reason: Postictal sleepiness and lethargy are common after generalized seizures due to neuronal exhaustion and temporary metabolic changes in the brain. This is expected and not an emergency unless prolonged or accompanied by other concerning symptoms like respiratory distress.
Choice C reason: Falling at seizure onset is typical in generalized seizures due to loss of muscle control. Unless injury (e.g., head trauma) is suspected, it does not warrant an immediate 911 call, as it is a common seizure manifestation.
Choice D reason: Postictal confusion and slurred speech are normal after a generalized seizure, reflecting temporary cortical dysfunction. These resolve within minutes to hours and do not require emergency services unless persistent or associated with other critical symptoms like unresponsiveness.

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What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

Explanation

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Correct Answer is A

Explanation

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