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. "I'm sure the voices will go away soon." B. "Let's talk about what the voices are saying to you." C. "You should talk to your counselor about the voices." D. "Tell me what medications you are taking."

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.

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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

Explanation

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?

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