A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
Turn the child onto their back.
Restrain the child's upper extremities.
Place a padded tongue blade in the child's mouth.
Place a pillow under the child's head.
The Correct Answer is D
The correct action to take in this situation is to place a pillow or cushion under the child's head.
This will help protect the child from injuring their head during the seizure.
It is important not to turn the child onto their back during a seizure, as this can obstruct the airway and potentially lead to respiratory distress.
Restraining the child's upper extremities is also not recommended, as it can cause injury to the child or the person trying to restrain them.
Placing a padded tongue blade or any object in the child's mouth is no longer recommended during a seizure. Doing so can cause injury to the child's mouth or teeth and is not necessary for seizure management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Veracity refers to the ethical principle of truthfulness and honesty in communication. By communicating truthfully about the adverse effects of the client's prescribed medications, the nurse is practising veracity. This means providing accurate and complete information to the client, enabling them to make informed decisions about their healthcare.
Beneficence refers to the obligation of healthcare professionals to act in the best interests of the client and promote their well-being. While the nurse's actions may align with beneficence by providing information about medication adverse effects, it is specifically veracity that is demonstrated in this scenario.
Justice pertains to fairness and equal treatment. Although important in healthcare, it is not directly related to the nurse's communication of adverse effects.
Autonomy refers to respecting and supporting the client's right to make their own decisions about their care. While the nurse's truthful communication about adverse effects supports the client's autonomy, it is the concept of veracity that specifically addresses honesty and truthfulness in communication.
Correct Answer is A
Explanation
This statement should be included in the change-of-shift report because it provides vital information about the patient’s condition and any changes that have occurred to the patient during the shift.
Statement B is wrong because it does not provide relevant information about the patient’s current condition or changes that have occurred during the shift. Statement C is wrong because it does not provide relevant information about the patient’s medical condition. Statement D is wrong because it does not provide new information about changes that have occurred during the shift.
Change-of-shift reports are key to inpatient care because they provide vital information about and responsibility for the patient from the off-going provider to the on-coming provider.
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