A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?
Sleepiness
Restlessness
Anxiety
Nausea
The Correct Answer is A
A. This is a common postictal manifestation after a generalized tonic-clonic seizure. Following the intense muscle activity and convulsions during the seizure, the child may experience exhaustion and feel sleepy. The postictal state often involves a period of drowsiness or even brief loss of consciousness.
B. Restlessness is less likely to be observed immediately after a generalized tonic-clonic seizure. Instead, the child is more likely to exhibit fatigue and lethargy as the body recovers from the seizure activity.
C. Anxiety may occur during or immediately after the seizure due to the sudden and frightening nature of the event. However, in the postictal period, anxiety typically diminishes as the child becomes more oriented and aware of their surroundings.
D. Nausea is not a typical postictal manifestation after a generalized tonic-clonic seizure. While some individuals may experience nausea or vomiting during the seizure (ictal phase), it is less common in the postictal period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
B. Wheezing is a common symptom of asthma exacerbation and can indicate airway obstruction. Wheezing may worsen during an asthma attack, suggesting deterioration in respiratory status.
C. Nasal flaring is a sign of increased respiratory effort and can occur during respiratory distress. In a child with asthma, nasal flaring may indicate worsening airway obstruction and increased work of breathing, suggesting deterioration in respiratory status.
D. Retraction of sternal muscles, also known as intercostal retractions, occurs when the muscles between the ribs are drawn inward during inspiration, indicating increased effort to breathe. Intercostal retractions are a sign of respiratory distress and can occur in children with asthma during exacerbations, particularly when airway obstruction is severe.
A. Warm extremities are not typically indicative of deterioration in respiratory status in a child with asthma. In fact, warm extremities may suggest adequate peripheral perfusion.
E. An oxygen saturation of 95% is within the normal range for most children and may not necessarily indicate deterioration in respiratory status. However, oxygen saturation should be interpreted in conjunction with other clinical signs and symptoms.
Correct Answer is B
Explanation
The nurse should ensure that the rope knots are positioned away from the pulleys to prevent interference with the traction mechanism. Proper alignment of the rope and pulleys ensures smooth traction application and prevents accidental slippage or dislodgment of the traction weights.
A. Buck's traction typically does not involve pin sites. It involves the application of traction to the affected limb using a boot or traction tape. Antibiotic ointment is not typically applied to the skin under Buck's traction unless there are specific wounds or abrasions that require treatment.
C. Ensuring the child's feet are against the footboard is not applicable to Buck's traction, which does not require the feet to be against a footboard.
D. There is typically no need to reduce a child's fluid intake solely because they are in Buck's traction for Legg-Calve-Perthes disease. Adequate hydration is essential for overall health and healing, and fluid restriction is not indicated unless there are specific medical reasons for doing so.
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