A male child is being prepared for a computed tomography (CT) scan when he begins to have a tonic clonic seizure. His mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? (Select all that apply.)
Close blinds room so is darkened.
Ask the mother to release the child.
Monitor the child's airway and tongue.
Administer an anticonvulsant medication.
Place pillows inside the side rails.
Correct Answer : B,C,E
A. Closing the blinds room so is darkened is inappropriate. The lighting in the room is unlikely to have an impact on the seizure or its management. Ensuring safety and maintaining the airway is the priority.
B. Asking the mother to release the child is appropriate. It’s important to ensure the safety of both the child and the mother. The mother should be asked to release the child to prevent any potential harm to the child during the seizure
C. Monitoring the child's airway and tongue is appropriate. During a seizure, there is a risk of the child's airway being compromised. The nurse should closely monitor the child's airway to ensure that it remains open and that the tongue does not obstruct the airway. Positioning the child on their side can also help prevent choking.
D. Administering an anticonvulsant medication is inappropriate. The nurse should not administer medication without a healthcare provider's order. In a seizure emergency, the focus is on maintaining safety and managing the seizure itself.
E. Place pillows inside the side rails: This is a correct action to prevent injury during the seizure. Padding the side rails helps protect the child from hitting their head or limbs on the hard surfaces.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
C. Albuterol: Albuterol is a bronchodilator that helps to relieve bronchoconstriction and improve airflow. It is commonly used to treat wheezing and respiratory distress in conditions like croup.
D. Racemic epinephrine: Racemic epinephrine is a vasoconstrictor and bronchodilator that can help reduce upper airway edema and improve breathing. It is often used in the treatment of croup to alleviate stridor.
Incorrect answers:
A. 5% dextrose: Dextrose is a type of sugar solution used for various purposes, including providing energy. However, it is not indicated for the immediate management of inspiratory stridor and respiratory distress.
B. Acetaminophen: Acetaminophen is a fever and pain reducer. While fever control might be important, it doesn't address the child's primary respiratory symptoms.
E. Morphine: Morphine is an opioid analgesic and can depress the respiratory drive. It is not indicated for the treatment of respiratory distress in a child with inspiratory stridor.
F. Aspirin: Aspirin is not recommended for use in children due to the risk of Reye's syndrome, a potentially serious condition. Additionally, aspirin does not address the child's respiratory symptoms.
Correct Answer is B
No explanation
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