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 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.

A. The presence of protein in the urine B. Signs of increased intracranial pressure C. Signs of hyperglycemia D. Signs of a bacterial infection

Correct Answer is B

Explanation

B. Reye's syndrome is characterized by swelling of the brain (cerebral edema), which can lead to increased intracranial pressure (ICP). Monitoring for signs of increased ICP, such as changes in level of consciousness, headache, vomiting, and altered pupil size and reactivity, is crucial for early detection and intervention to prevent neurological deterioration.

A. Reye's syndrome primarily affects the liver and brain, leading to liver dysfunction and encephalopathy. While renal involvement can occur in some cases, the priority complication typically relates to liver dysfunction and neurological manifestations rather than renal impairment.

C. Hyperglycemia may be present due to liver dysfunction and altered glucose metabolism, but it is not the primary concern compared to neurological complications and hepatic failure.

D. Reye's syndrome is not caused by a bacterial infection; it is typically associated with viral illnesses, particularly influenza and varicella (chickenpox).

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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

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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Correct Answer is B

Explanation

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