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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.)

Restrain the client.

Assess the client’s airway patency.

Remove objects from the client’s bed.

Place the client in a side-lying position.

Place a tongue depressor in the client’s mouth.

Answer and Explanation

Correct Answer : B,C,D

The correct answers are B. Assess the client’s airway patency,

C. Remove objects from the client’s bed, and D. Place the client in a side-lying position.

Choice A rationale

Restraining the client during a seizure is not recommended as it can cause injury. The focus should be on ensuring the client’s safety and preventing harm.

Choice B rationale

Assessing the client’s airway patency is crucial during a seizure to ensure that the client is breathing properly and that the airway is not obstructed.

Choice C rationale

Removing objects from the client’s bed helps prevent injury during a seizure. Objects in the bed can pose a risk of harm if the client hits them during the seizure.

Choice D rationale

Placing the client in a side-lying position helps maintain an open airway and reduces the risk of aspiration. This position allows any secretions to drain out of the mouth, preventing choking.

Choice E rationale

Placing a tongue depressor in the client’s mouth is not recommended and can cause injury. It is a common misconception that this prevents the client from swallowing their tongue, but it can actually cause more harm.

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Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale

Encouraging progressive activity is generally beneficial for children with various health conditions, but it is not the primary focus for a child with polycythemia caused by a congenital heart disorder. The main concern is managing the increased blood viscosity and preventing complications related to it.

Choice B rationale

Expecting the skin to turn yellow is not a typical symptom of polycythemia. Jaundice is more commonly associated with liver conditions or hemolytic diseases, not polycythemia caused by congenital heart disorders.

Choice C rationale

Preparing for seizures is not directly related to polycythemia. Seizures are more commonly associated with neurological conditions or severe electrolyte imbalances, not polycythemia.

Choice D rationale

Preventing dehydration is crucial for children with polycythemia because dehydration can increase blood viscosity, leading to a higher risk of thrombotic events. Ensuring adequate hydration helps maintain proper blood flow and reduces the risk of complications.

A. Hirschsprung’s disease. B. Encopresis. C. Pyloric stenosis. D. Enterocolitis.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale

Hirschsprung’s disease is characterized by inadequate motility of part of the intestine, resulting in a mechanical obstruction. This condition is caused by the absence of ganglion cells in the affected segment of the intestine, leading to a lack of peristalsis and subsequent obstruction.

Choice B rationale

Encopresis is a condition characterized by the repeated passage of feces into inappropriate places, such as clothing or the floor. It is not associated with inadequate motility of the intestine or mechanical obstruction.

Choice C rationale

Pyloric stenosis is a condition characterized by the narrowing of the pylorus, which leads to obstruction of the passage of food from the stomach to the small intestine. It is not associated with inadequate motility of the intestine.

Choice D rationale

Enterocolitis is an inflammation of the intestine and colon. It is not associated with inadequate motility of the intestine or mechanical obstruction.

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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

Which health teaching concept should the nurse emphasize when instructing the parents of a child with polycythemia caused by a congenital heart disorder?

Correct Answer is D

Explanation

A nurse is caring for an infant who has inadequate motility of part of the intestine resulting in a mechanical obstruction.The nurse should identify this finding as a manifestation of which of the following disorders?

Correct Answer is A

Explanation

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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.)