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.)
Place a tongue depressor in the client's mouth.
Restrain the client.
Assess the client's airway palenty
Remove objects from the client's bed
Place the client in a side-lying position
Correct Answer : C,D,E
A) Place a tongue depressor in the client's mouth:
Incorrect. Placing a tongue depressor in the client's mouth is not recommended during a seizure. Doing so can lead to injury, as the child may bite down on the depressor and cause harm to their teeth or mouth.
B) Restrain the client:
Incorrect. Restraining a person during a seizure can be extremely dangerous. It can lead to physical harm to both the person experiencing the seizure and the person trying to restrain them. Restraining can increase the risk of fractures, dislocations, and other injuries.
C) Assess the client's airway patency:
Correct. Assessing the client's airway patency is essential during a seizure. The nurse should ensure that the child's airway is clear and open to maintain proper breathing. This involves observing for any obstruction or difficulty in breathing and taking appropriate measures to keep the airway open.
D) Remove objects from the client's bed:
Correct. Removing objects from the client's bed is a necessary action to prevent injury during a seizure. Objects on the bed can pose a risk of harm to the child if they were to strike them during the seizure. Creating a safe environment by removing potential hazards is important.
E) Place the client in a side-lying position:
Correct. Placing the client in a side-lying position is recommended during a seizure. This position helps prevent aspiration and maintains a clear airway. It also reduces the risk of choking and allows any fluids to drain from the mouth, minimizing the risk of choking.
In summary:
Choice A is incorrect because placing a tongue depressor can cause injury.
Choice B is incorrect because restraining can lead to harm.
Choice C is correct because assessing the airway ensures proper breathing.
Choice D is correct because removing objects reduces the risk of injury.
Choice E is correct because placing the client in a side-lying position helps maintain a clear airway and prevents aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Type 1 diabetes mellitus is a condition where the body's immune system mistakenly attacks and destroys the insulin-producing cells in the pancreas. Individuals with type 1 diabetes require insulin therapy to manage their blood sugar levels. Since the question is about teaching an adolescent with type 1 diabetes, let's analyze each option:
A) Obtain an influenza vaccine annually:
This is a crucial recommendation. People with diabetes, including type 1 diabetes, have a higher risk of complications from infections, including influenza (the flu). The flu can lead to elevated blood sugar levels and potentially worsen diabetes control. Getting an annual influenza vaccine helps reduce the risk of getting the flu and its associated complications.
B) Take glyburide with breakfast:
Glyburide is a medication used to treat type 2 diabetes, not type 1 diabetes. It stimulates the pancreas to produce more insulin. Type 1 diabetes is characterized by a lack of insulin production, so taking glyburide would not be appropriate.
C) Administer glucagon for hyperglycemia:
Glucagon is a hormone used to raise blood sugar levels, typically in cases of severe hypoglycemia (low blood sugar). It is not used to treat hyperglycemia (high blood sugar) in type 1 diabetes. Instead, insulin administration is the primary method for managing high blood sugar levels.
D) Inject insulin in the deltoid muscle:
Insulin injections for individuals with type 1 diabetes are typically given in the subcutaneous fat, which is found just beneath the skin. The deltoid muscle is not a recommended site for insulin injections due to inconsistent absorption. The abdomen, thighs, and buttocks are commonly recommended injection sites.
Correct Answer is A
Explanation
A. "I will continue to check his blood sugar two times every day."
Correct Explanation: This statement indicates a need for further instruction.
Explanation: A child with type 1 diabetes requires frequent blood sugar monitoring, especially during illness. Checking blood sugar only twice a day is not sufficient, especially when the child has an upper respiratory infection. Illness can impact blood sugar levels, so more frequent monitoring is necessary to ensure proper diabetes management.
B. "I will report a change in her breathing or any signs of confusion."
Incorrect Explanation: This statement shows awareness of potential complications and the need to monitor for them.
Explanation: Children with type 1 diabetes are at risk of diabetic ketoacidosis (DKA) when they are sick. Changes in breathing patterns and signs of confusion are symptoms of DKA. Reporting these symptoms is important, as it could indicate a serious diabetic complication.
C. "I will encourage her to drink half a cup of water or sugar-free fluid every 30 minutes."
Incorrect Explanation: This statement demonstrates proper fluid management, especially during illness.
Explanation: Encouraging the child to stay hydrated with sugar-free fluids is essential, particularly when the child has an upper respiratory infection. Proper hydration helps prevent dehydration, which can be more concerning for a child with diabetes.
D. "I will notify the doctor if her temperature is not controlled by acetaminophen."
Incorrect Explanation: This statement shows an understanding of the importance of managing fever in a child with diabetes.
Explanation: Children with diabetes can experience difficulty managing blood sugar levels when they're sick. Fever can exacerbate this issue. Using acetaminophen to control fever is appropriate, and notifying the doctor if fever persists is a responsible action.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.