A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure.

Which of the following actions should the nurse take?

Oﬀer the child sips of clear ﬂuids.

Place the child in a supine position.

Administer an oral antiepileptic medication.

Check the child for oral injuries.

Answer and Explanation

The Correct Answer is D

After a tonic-clonic seizure, the nurse should first check the child for any injuries, particularly in the oral cavity. This is because during a seizure, the child's tongue may have been biten, or there may be other oral injuries. Therefore, it is essential to check the oral cavity for any injury or bleeding.

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Correct Answer is A

Explanation

a. Sounds are high-pitched.

Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as in diarrhea, gastroenteritis, or early bowel obstruction.

Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.

Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.

Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.

A. Report the incident to the charge nurse. B. Participate in an in-service about client confidentiality. C. Tell the staff members to stop their discussion. D. Speak to the staff members in private about client confidentiality.

Correct Answer is C

Explanation

a.While reporting the incident is important, the priority is to stop the confidentiality breach immediately to protect the client's privacy.

b.Participating in training is important for long-term education, but it does not address the immediate issue of the confidentiality breach.

c. Tell the staff members to stop their discussion: This action stops the breach immediately and protects the client's confidential information, which is the first and most crucial step.

d.Speak to the staff members in private about client confidentiality: While this is a good follow-up action to educate and prevent future breaches, the immediate need is to stop the ongoing discussion

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A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?

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A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure.

Which of the following actions should the nurse take?