A child is being prepared for a computed tomography (CT) scan when the child begins to have a tonic clonic seizure.The mother is hysterical and is trying to hold the child down.
Which action(s) should the nurse take? Select all that apply.
A. Place pillows inside the side rails.
Place pillows inside the side rails.
Ask the mother to release the child.
Administer an anticonvulsant medication.
Close the blinds to darken the room.
Monitor the child's airway and tongue.
Correct Answer : B,C,E
Choice A rationale
While placing pillows inside the side rails can prevent injury, it may not be effective if the child is having a severe tonic-clonic seizure, as the child could still injure themselves. Padding the entire bed with approved padding is more appropriate in such a case.
Choice B rationale
During a seizure, it is crucial to ensure the child’s safety by asking the mother to release the child to prevent unintentional injury. Holding the child down during a seizure can cause harm to both the child and the mother, and it's important to provide a safe space for the child to move.
Choice C rationale
Administering an anticonvulsant medication can help control the seizure and prevent further convulsions. Medications such as benzodiazepines are often used to treat ongoing seizures and can provide rapid relief.
Choice D rationale
Closing the blinds to darken the room is not directly beneficial during a seizure and does not address the immediate need to protect the child from injury or manage the seizure effectively. While reducing light may help in other conditions, it is not a priority during a seizure.
Choice E rationale
Monitoring the child's airway and tongue is critical to ensure they are not at risk of choking or aspiration during a seizure. Keeping the airway clear and observing for any obstructions can prevent further complications and ensure the child’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Encouraging the child to dress in clothing that suits her sexual maturity level is not an appropriate approach for managing precocious puberty. The goal of treatment with LHRH is to delay further development until the appropriate age, allowing the child to dress according to her chronological age rather than her advanced physical maturity.
Choice B rationale
The purpose of LHRH therapy is to regulate and normalize the child's hormonal levels, which can slow or stop the progression of precocious puberty. As the therapy takes effect, differences in sexual maturity between the child and her peers should diminish over time, allowing her development to align more closely with her age group.
Choice C rationale
LHRH treatment for precocious puberty is typically not lifelong. It is used to delay puberty until a more appropriate age. Once treatment is stopped, the child's body will resume normal pubertal development. Parents should understand that the therapy is temporary and aimed at managing early onset puberty.
Choice D rationale
Starting the child on birth control pills is not a standard treatment for precocious puberty. The goal of LHRH therapy is to manage hormonal levels to delay puberty, not to prevent pregnancy. Birth control pills are not necessary and do not address the underlying condition being treated with LHRH therapy. .
Correct Answer is D
Explanation
Choice A rationale
Iron is essential for preventing anemia, particularly in pregnant women, but it does not prevent neural tube defects like anencephaly. Iron supports overall maternal and fetal health but is not specific to preventing congenital anomalies.
Choice B rationale
Calcium is crucial for fetal bone development and maternal bone health, but it does not play a role in preventing anencephaly. Adequate calcium intake is important during pregnancy but is not linked to neural tube defect prevention.
Choice C rationale
Vitamin D is important for bone health and immune function but does not prevent neural tube defects. Sufficient vitamin D levels are necessary for the mother's and baby's health but are not related to anencephaly prevention.
Choice D rationale
Folic acid is the correct choice as it has been shown to prevent neural tube defects, including anencephaly and spina bifida. It is recommended that women of childbearing age take folic acid supplements before conception and during early pregnancy to reduce the risk of these congenital anomalies.
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