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 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).

A. Improve muscle control and coordination. B. Eliminate the cause of the disease. C. Prevent the occurrence of emotional disturbances. D. Maximize the child's assets and minimize the limitations.

Correct Answer is D

Explanation

D. The aim is to focus on the child's strengths and abilities while addressing limitations and challenges associated with the condition. This approach emphasizes maximizing the child's potential for development, independence, and participation in daily activities, education, and social interactions, while also providing support and resources to address any limitations or barriers they may encounter.

A. Another goal of treatment and care is to maximize the child's functional abilities by improving muscle control, coordination, and mobility through various therapies, such as physical therapy, occupational therapy, and speech therapy. However, this is not the primary goal.

B. Cerebral palsy is a neurological condition caused by damage to the developing brain, often occurring before birth. While efforts to prevent cerebral palsy are important, once the condition has developed, the focus shifts to managing symptoms and optimizing the child's functioning rather than eliminating the cause.

C. Emotional well-being is an important aspect of overall health for children with cerebral palsy but it is not typically the primary goal of care. Emotional disturbances may occur in some children with cerebral palsy due to various factors such as coping with the challenges of the condition, social interactions, or other comorbidities, but the primary focus of the care plan is usually on addressing physical and functional impairments.

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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 reviews the plan of care for a child with Reye's syndrome. The nurse plans to monitor for which priority complication of this syndrome?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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