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 B

Explanation

This response acknowledges the client's experience and shows a willingness to understand and address their concerns.

It opens up a dialogue about the hallucinations, allowing the nurse to gather more information and assess the client's current mental state. It also demonstrates empathy and support, which can help build trust between the nurse and the client.

Offering to discuss the voices with the client can also help in developing coping strategies and exploring potential interventions to manage the hallucinations effectively.

A. Apply pressure to the lacrimal punctum after administering the drops. B. Position the child side-lying on the bed before administering the drops. C. Wipe from the outer to the inner canthus after administering the drops. D. Flush the eye with normal saline solution before administering the drops.

Correct Answer is A

Explanation

a. Apply pressure to the lacrimal punctum after administering the drops.

When administering eye drops to a child, the nurse should apply gentle pressure to the lacrimal punctum (the small opening in the inner corner of the eye) after administering the drops. This can help prevent the medication from draining into the tear duct and being absorbed into the bloodstream, which can reduce systemic side eﬀects.

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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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Explanation

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