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

Answer and Explanation

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.

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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.

A. The fact that the patient is male B. The fact that the patient is female. C. Developmental milestones D. The number of urinary tract infections the patient has had

Correct Answer is ["C","D"]

Explanation

A. The fact that the patient is male

Incorrect Explanation: The patient's gender does not directly provide important information about the history of reflux.

Explanation: Vesicoureteral reflux (VUR), which is the retrograde flow of urine from the bladder into the ureters, can affect individuals of any gender. While gender might have some implications for certain conditions, it is not a critical factor in understanding the history of reflux.

B. The fact that the patient is female.

Incorrect Explanation: The patient's gender does not directly provide important information about the history of reflux.

Explanation: Just like with the previous option, the patient's gender does not play a significant role in the history of vesicoureteral reflux. The condition can affect both males and females.

C. Developmental milestones

Correct Explanation: Developmental milestones are important in understanding the history of reflux.

Explanation: Developmental milestones are significant because VUR is more common in infants and young children. Infants and young children have a higher likelihood of developing reflux due to the immaturity of their urinary tract systems. Knowing about the patient's developmental milestones can help assess the risk and potential severity of reflux.

D. The number of urinary tract infections the patient has had

Correct Explanation: The number of urinary tract infections (UTIs) is important in understanding the history of reflux.

Explanation: Repeated urinary tract infections can be a sign of vesicoureteral reflux. The backflow of urine from the bladder into the ureters can contribute to UTIs. Monitoring the frequency of UTIs can provide insights into the presence and severity of reflux.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching?

Correct Answer is A

Explanation

We know that reflux refers to the retrograde flow of bladder urine into the ureters, which of the following items are important information in the patient’s history? (Select All that Apply)

Correct Answer is ["C","D"]

Explanation

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