A nurse is caring for a child during a tonic-clonic seizure. Which of the following actions should the nurse take? (Select all that apply)
Loosen tight clothing around the child's neck.
Firmly hold the child's arms to one side.
Place a pillow under the child's head.
Insert a tongue blade into the child's mouth.
Clear the area of hard objects.
Correct Answer : A,C,E
Choice A reason: Loosening tight clothing around the child's neck is important to ensure that the child can breathe easily and to prevent any additional discomfort or injury during the seizure.
Choice B reason: It is not recommended to firmly hold the child's arms to one side as this can cause injury. Instead, the nurse should ensure the child's safety by clearing the area of any hard or sharp objects.
Choice C reason: Placing a pillow under the child's head can help to protect the head from injury during the seizure. It provides a soft cushion to prevent the child from hitting their head on hard surfaces.
Choice D reason: Inserting a tongue blade into the child's mouth is not advised as it can cause injury to the child's mouth or teeth, and there is a risk of the child biting down and breaking the blade.
Choice E reason: Clearing the area of hard objects is crucial to prevent injury to the child during the seizure. Removing any potential hazards ensures a safer environment for the child to move without harm.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Administering the varicella vaccine to a child with leukemia and a low neutrophil count is not recommended because live vaccines are contraindicated due to the child's compromised immune system.
Choice B reason: Increasing the child's intake of fresh fruit is not advisable in this case because fresh fruits may carry bacteria that can cause infection in a child with a low neutrophil count.
Choice C reason: Avoiding rectal temperature measurements is important to prevent potential injury and infection in a child with a low neutrophil count, as their immune system is weakened.
Choice D reason: Restricting bathing to every other day is not necessary unless the child's skin is extremely sensitive due to chemotherapy. Regular bathing helps maintain hygiene and comfort.
Correct Answer is C
Explanation
Choice A reason: Assessing the child's pulse and respirations can indicate pain through physiological changes, but these signs can be influenced by other factors and may not provide an accurate measure of pain intensity.
Choice B reason: Observing the child's facial expressions can give some indication of pain, but it is subjective and may not accurately reflect the child's pain experience, especially if the child is trying to hide their discomfort.
Choice C reason: Asking the child to use a FACES rating scale allows the child to actively participate in communicating their pain level. This method is age-appropriate and provides a visual way for children to express the intensity of their pain, making it a reliable assessment technique.
Choice D reason: Monitoring the child's involuntary movements can provide clues about pain, but like facial expressions, they are subjective and may not accurately quantify the child's pain level.
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