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 A
Explanation
Choice A reason: Slurred speech may indicate a stroke or other neurological complication, which is a medical emergency. Sickle cell anemia can lead to such complications, and immediate assessment is crucial.
Choice B reason: While a partial-thickness burn requires care, it is not as immediately life-threatening as potential neurological complications. The toddler should be assessed after more urgent cases.
Choice C reason: A pain level of 7 is significant, but pain management can be addressed after more critical needs are met. The adolescent's pain should be managed effectively once urgent cases are stabilized.
Choice D reason: Administering an IV bolus of nafcillin for osteomyelitis is important, but it does not take precedence over potential neurological issues. The toddler should receive the medication promptly after urgent assessments.
Correct Answer is C
Explanation
Choice A reason: Talking to a toddler about the meaning of death may not be appropriate or helpful, as they may not fully understand the concept. It's important to provide comfort rather than potentially causing confusion or distress.
Choice B reason: While encouraging friends to visit can provide social support, it may not always be feasible or in the best interest of the child's health, especially if the child is very ill or immunocompromised.
Choice C reason: Staying close to the child provides emotional support and comfort, which is crucial during this difficult time. Physical presence and affection can be very reassuring for both the child and the parents.
Choice D reason: Changing the child's schedule every day can be disruptive and may cause additional stress. Consistency and routine can provide a sense of security and stability for a child who is terminally ill.
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