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.

Answer and Explanation

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.

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Correct Answer is A

No explanation

A. Elbow restraints B. The child's favorite toy C. Manual resuscitation bag D. A dose of subcutaneous epinephrine E. An advanced airway kit F. Nebulised albuterol

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

Explanation

C. Manual resuscitation bag: In the case of a child with inspiratory stridor and retractions, there is a concern about airway obstruction. Having a manual resuscitation bag available is crucial to ensure that the child's airway can be effectively managed in case of respiratory distress.

E. An advanced airway kit: If the child's condition worsens and he experiences severe respiratory distress or failure, an advanced airway may be necessary to secure the airway and provide proper oxygenation. Having an advanced airway kit available is important in case intubation becomes necessary.

Incorrect answers:

A. Elbow restraints: Elbow restraints are not typically used during peripheral intravenous line placement. They are used to prevent children from bending their arms excessively after specific surgeries or procedures.

B. The child's favorite toy: While having a favorite toy might help distract the child and reduce anxiety, it is not a critical item needed for the placement of a peripheral intravenous line.

D. A dose of subcutaneous epinephrine: Subcutaneous epinephrine is not used for the placement of an intravenous line. It is typically used to treat severe allergic reactions (anaphylaxis).

F. Nebulized albuterol: Nebulized albuterol is a medication used to treat bronchospasm in conditions such as asthma. While the child is experiencing respiratory distress, the priority is to secure the airway and provide oxygenation, which may involve using a manual resuscitation bag and an advanced airway kit.

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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.)

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