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 C
Explanation
Correct Answer is ["C","D","E"]
Explanation
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.
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