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.
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Related Questions
Correct Answer is D
Explanation
A. Using a suppository for bowel movement is a common approach for managing bowel function in people with paralysis and is appropriate.
B. Carrying a water bottle to stay hydrated is important, especially since individuals with paralysis may be at increased risk of urinary tract infections. Adequate hydration is beneficial.
C. Doing wheelchair exercises while watching TV is a proactive way to maintain muscle tone and overall health, which is crucial for individuals with paralysis.
D. "I only need to catheterize myself twice every day!"
Explanation: In the context of spina bifida and paralysis from the waist down, catheterization is often required for bladder management. Individuals with this condition often experience urinary retention and require intermittent catheterization to empty their bladder. However, "twice every day" is not usually sufficient for someone with paraplegia. Adequate catheterization frequency is crucial to prevent urinary retention, infections, and other complications.
Correct Answer is D
Explanation
A. Elevated blood glucose is remarkable with Cushing's Triad:
Elevated blood glucose is not one of the components of Cushing's Triad. The triad focuses on cardiovascular and respiratory changes associated with increased intracranial pressure, not blood glucose levels.
B. Cushing's Triad includes a positive Macawen's sign:
Macawen's sign is not part of Cushing's Triad. Cushing's Triad is specifically related to the physiological responses seen in response to increased intracranial pressure and is not associated with Macawen's sign.
C. Cushing's Triad includes tachycardia, seizures and rapid respirations:
This option is not accurate. Cushing's Triad involves bradycardia (slow heart rate), irregular respirations, and a widening pulse pressure. Tachycardia (rapid heart rate) and seizures are not part of Cushing's Triad but might be indicative of other medical conditions or complications.
D. Bradycardia, irregular respirations and a widening pulse pressure.
Explanation: Cushing's Triad is a set of three clinical signs that are indicative of increased intracranial pressure (ICP) and are considered ominous as they suggest serious brain injury or pathology. The triad consists of:
Bradycardia: This refers to a slow heart rate. As intracranial pressure increases, it can lead to a decreased heart rate due to pressure on the brainstem, which is involved in regulating heart rate.
Irregular Respirations: Increased ICP can affect the brainstem's control over breathing, leading to irregular patterns of breathing, often known as Cheyne-Stokes respiration. This is characterized by periods of rapid breathing followed by apnea (temporary cessation of breathing).
Widening Pulse Pressure: Pulse pressure is the difference between systolic and diastolic blood pressure. An increase in ICP can cause an increase in systolic blood pressure and a decrease in diastolic blood pressure, leading to a widening pulse pressure.
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