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. Suctioning equipment and oxygen are essential items to have at the bedside for seizure precautions. Seizures can sometimes be associated with airway compromise, excessive secretions, or respiratory distress. Having suctioning equipment readily available allows for prompt removal of oral or airway secretions if necessary. Oxygen may be needed to support oxygenation during or after a seizure, especially if there are concerns about respiratory depression or hypoxemia.

A. A tracheotomy set is not typically needed at the bedside for seizure precautions. Tracheotomy sets are used in emergency situations to establish a surgical airway if there is a severe airway obstruction or respiratory distress.

B. An emergency cart contains essential supplies and medications needed for emergency situations, including resuscitation equipment, medications, and supplies for managing various medical emergencies. However, the cart is not placed bedside.

C. A padded tongue blade is not typically needed at the bedside for seizure precautions. Tongue blades are sometimes used during airway management to help visualize and manipulate the tongue, but padded tongue blades are not routinely included in seizure precautions.

A. Sleepiness B. Restlessness C. Anxiety D. Nausea

Correct Answer is A

Explanation

A. This is a common postictal manifestation after a generalized tonic-clonic seizure. Following the intense muscle activity and convulsions during the seizure, the child may experience exhaustion and feel sleepy. The postictal state often involves a period of drowsiness or even brief loss of consciousness.
B. Restlessness is less likely to be observed immediately after a generalized tonic-clonic seizure. Instead, the child is more likely to exhibit fatigue and lethargy as the body recovers from the seizure activity.

C. Anxiety may occur during or immediately after the seizure due to the sudden and frightening nature of the event. However, in the postictal period, anxiety typically diminishes as the child becomes more oriented and aware of their surroundings.
D. Nausea is not a typical postictal manifestation after a generalized tonic-clonic seizure. While some individuals may experience nausea or vomiting during the seizure (ictal phase), it is less common in the postictal period.

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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 develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which of the item(s) need to be placed at the child bedside?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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