A nurse is caring for a child who is having a seizure.
Which of the following actions should the nurse take? (Select all that apply.)
Restrain the client.
Place the client in a side-lying position.
Place a tongue depressor in the client’s mouth.
Assess the client’s airway patency.
Remove objects from the client’s bed.
Correct Answer : B,D,E
Choice A rationale
Restraining a child during a seizure is not recommended. It does not stop the seizure and can lead to injury. The child’s movements during a seizure are involuntary, so trying to stop them can cause harm.
Choice B rationale
Placing the child in a side-lying position is recommended during a seizure. This position helps to prevent aspiration, which can occur if the child vomits during the seizure.
Choice C rationale
It is a common misconception that a person having a seizure can swallow their tongue, but this is not true. Attempting to place a tongue depressor or any other object in the child’s mouth during a seizure can cause injury to the child’s teeth or jaw.
Choice D rationale
Assessing the child’s airway patency is crucial during a seizure. Seizures can cause changes in breathing patterns and can potentially lead to respiratory distress. Therefore, monitoring the child’s breathing during a seizure is important.
Choice E rationale
Removing objects from the child’s bed or surrounding area can help prevent injury during a seizure. During a seizure, the child may have uncontrolled movements, and removing nearby objects can help ensure the child’s safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Step 1 is: Calculate the Apgar score based on the given vital signs. The Apgar score is calculated based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color.
Step 2 is: Assign points for each criterion. For heart rate of 160 bpm, assign 2 points. For good, vigorous respiratory effort, assign 2 points. For active movement and well-flexed muscle tone, assign 2 points. For crying with stimulation of soles of feet (reflex irritability), assign 2 points. For body pink but feet and hands cyanotic (color), assign 1 point.
Step 3 is: Add up the points. 2 (heart rate) + 2 (respiratory effort) + 2 (muscle tone) + 2 (reflex irritability) + 1 (color) = 9 points. So, the correct Apgar score for this newborn is 9.
Correct Answer is B
Explanation
Choice A rationale
While an ASO titer test can be used in the diagnosis of rheumatic fever, it does not directly indicate if a child has rheumatic fever. Rheumatic fever is a complication that can occur after a streptococcal infection, and it involves multiple systems in the body, not just the presence of streptococcal antibodies.
Choice B rationale
An ASO titer test measures the antibodies produced by your body in response to a toxin known as streptolysin O, which is produced by group A Streptococcus (GAS) bacteria. Your body makes the antistreptolysin O antibodies when you have a strep infection caused by GAS bacteria. Therefore, a positive ASO titer test can confirm if your child had a recent streptococcal infection.
Choice C rationale
An ASO titer test does not measure the blood level of an aminoglycoside or any other therapeutic drug. Aminoglycosides are a class of antibiotics used to treat bacterial infections, and their levels in the blood are typically monitored with specific drug level tests, not an ASO titer.
Choice D rationale
An ASO titer test does not confirm if your child has immunity to streptococcal bacteria. The presence of ASO antibodies indicates a recent infection, but it does not provide information about the immune status or protection against future infections.
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