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 D
Explanation
A. Polyuria (excessive urination) is not a symptom of hypoglycemia; it is more commonly associated with hyperglycemia (high blood sugar).
B. Deep rapid respirations are more characteristic of diabetic ketoacidosis (DKA), a complication of uncontrolled diabetes that leads to high blood sugar levels and metabolic acidosis.
C. Dry, flushed skin is not a typical symptom of hypoglycemia; it might be associated with conditions like dehydration or heat exposure, but not with low blood sugar.
D. Tachycardia
Explanation: The symptoms described by the adolescent (feeling shaky, difficulty speaking, difficulty concentrating) along with a blood glucose level of 55 mg/dL indicate hypoglycemia, which is low blood sugar. Tachycardia, or a rapid heart rate, is a common physiological response to hypoglycemia. The body increases the heart rate in an attempt to improve blood flow and deliver glucose to the brain and other vital organs. This is part of the body's fight-or-flight response to low blood sugar.
Correct Answer is C
Explanation
A. "We worry about surgery. Do you think we should investigate direct donation of blood?"
Explanation: This statement doesn't show a clear understanding of nephrotic syndrome. Nephrotic syndrome is a kidney disorder that involves the kidneys' ability to filter blood, but it doesn't typically involve blood donation or surgery related to that. Direct donation of blood is not relevant to the treatment or management of nephrotic syndrome.
B. "We'll have to encourage lots of liquids. Did you say about Biters per day?"
Explanation: This statement suggests a misunderstanding of nephrotic syndrome and its management. Encouraging lots of liquids is generally not a primary concern in nephrotic syndrome. In fact, excess fluid intake might be counterproductive, as it could worsen edema (swelling) that often occurs with this condition. Additionally, the term "Biters per day" doesn't seem relevant to nephrotic syndrome or its management.
C. "My child really likes chips and bologna. I guess we will have to find something else."
Explanation: This statement indicates an understanding of dietary considerations related to nephrotic syndrome. Nephrotic syndrome involves protein loss through the urine, which can lead to low protein levels in the blood. To address this, dietary changes are often recommended to include foods rich in protein. Avoiding high-sodium foods like chips and bologna is also important, as excessive sodium intake can contribute to fluid retention and worsen edema.
D. "We understand the need for antibiotics, hope they can be given orally."
Explanation: This statement doesn't relate to nephrotic syndrome or its management. Nephrotic syndrome primarily involves issues with kidney function and protein loss, and antibiotics are not a standard treatment for this condition. Antibiotics are used to treat infections, which can sometimes be a complication of nephrotic syndrome due to the immune system's vulnerability, but the statement doesn't focus on the understanding of the disease itself.
Correct Answer: C. "My child really likes chips and bologna. I guess we will have to find something else."
Explanation: This statement shows an understanding of the dietary changes needed for a child with nephrotic syndrome. It acknowledges the importance of adjusting the child's diet to include protein-rich foods and avoid high-sodium options, which aligns with the nutritional considerations for managing nephrotic syndrome.
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