A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?

Apply oxygen by nasal cannula.

Administer an anticonvulsant medication.

Turn the client to a lateral position.

Check the client's oxygen saturation.

Answer and Explanation

The Correct Answer is C

C. The priority during a seizure is to protect the patient from harm, particularly from aspiration if they vomit or have excessive saliva production. Turning the client to a lateral position helps maintain an open airway and prevents aspiration. This action should be taken immediately after lowering the client to the floor to ensure their safety.

A. Providing oxygen is important for a patient experiencing a seizure. However, it's not the first action to take. The priority is to ensure the patient's safety and protect them from injury during the seizure.

B. Administering anticonvulsant medication during an active seizure is not appropriate. Anticonvulsants are typically prescribed as maintenance therapy to prevent seizures or to manage seizure disorders in a controlled manner, not during an acute seizure episode.

D. Monitoring oxygen saturation is important but it's not the first action to take during an active seizure. Ensuring the patient's safety and protecting them from injury take precedence. Oxygen saturation can be assessed once the patient is in a safe position.

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Correct Answer is ["A","B"]

Explanation

A. Humidified oxygen can help improve oxygenation and relieve respiratory distress by maintaining optimal humidity levels in the airways, which can be beneficial, especially in infants with bronchiolitis who may have increased respiratory secretions and airway inflammation.

B. Monitoring respiratory rate and oxygen saturation allows for early detection of respiratory distress and hypoxemia, which are common complications of bronchiolitis. Regular assessment helps guide interventions and ensures timely escalation of care if needed.

C. Restricting fluid intake is not typically indicated for children with bronchiolitis. In fact, maintaining adequate hydration is crucial for children with respiratory illnesses to help thin respiratory secretions and prevent dehydration.

D. Antibiotics are not routinely indicated for the treatment of bronchiolitis caused by viral pathogens. Bronchiolitis is typically caused by respiratory syncytial virus (RSV) or other viral infections, for which antibiotics are ineffective.

E. Chest physiotherapy is not routinely recommended for the management of bronchiolitis in infants and children. Bronchiolitis is primarily managed with supportive care measures such as humidified oxygen, hydration, and monitoring for respiratory distress.

A. Adduction of the arms at the shoulders B. Abnormal flexion of the upper extremities and extension and adduction of lower extremities C. Flaccid paralysis of all extremities D. Rigid extension and pronation of the arms and legs

Correct Answer is D

Explanation

D. This is the correct characteristic of decerebrate posturing. Decerebrate posturing is characterized by rigid extension and pronation (turning inward) of the arms and legs. It indicates severe neurological dysfunction and increased intracranial pressure, often involving damage to the brainstem.

A. This characteristic is not associated with decerebrate posturing. Adduction refers to movement toward the midline of the body, which is not typically observed in decerebrate posturing.

B. This description is not characteristic of decerebrate posturing. Decerebrate posturing involves extension, not flexion, of the upper extremities, along with extension and pronation (not adduction) of the lower extremities.

C. Flaccid paralysis refers to the absence of muscle tone and movement, which is not characteristic of decerebrate posturing. Decerebrate posturing involves increased muscle tone and abnormal, rigid extension of the arms and legs.

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A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following interventions are appropriate for nursing care of a child with bronchiolitis? (Select All that Apply.)

Correct Answer is ["A","B"]

Explanation

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Correct Answer is D

Explanation

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