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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The nurse should identify the sudden increase in energy as the priority finding to report to the provider. This could be a sign of an emerging manic episode, especially if the client is taking an antidepressant alone without a mood stabilizer.

It may indicate a switch to a manic state or the development of bipolar disorder. The provider needs to be informed promptly so that appropriate assessment and interventions can be implemented to ensure the client's safety and well-being.

A. Mental confusion B. Temperature C. Heart rate D. Urine output E. Pain F. Serum amylase level G. Respiratory status H. Sodium level I. Cold, clammy skin J. Blood pressure

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

Explanation

b. Ensure the chest tube remains below the level of the client's chest.

e. Reinforce loose dressing around the tube.

When managing a chest tube, it is important for the nurse to ensure that the chest tube remains below the level of the client's chest¹. This helps to prevent air from entering the pleural space and allows for proper drainage of ﬂuid. The nurse should also reinforce any loose dressing around the tube to maintain a secure seal¹.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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