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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale
Erikson’s stage of initiative versus guilt occurs in preschool-aged children (3-5 years), not toddlers.
Choice B rationale
Imaginary playmates are more common in preschool-aged children and are not a characteristic of toddlerhood.
Choice C rationale
Demonstrations of sexual curiosity are more common in preschool-aged children and are not a characteristic of toddlerhood.
Choice D rationale
Negative behaviors characterized by the need for autonomy are typical in toddlers. This stage, according to Erikson, is autonomy versus shame and doubt, where toddlers strive for independence and self-control.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Notifying the health care provider immediately may be necessary if the bleeding is severe or persistent. However, in the case of small amounts of blood, it is important to continue assessing for bleeding to determine if the situation worsens. Immediate notification may not be necessary for minor bleeding.
Choice B rationale
Continuing to assess for bleeding is the best intervention for a child spitting up small amounts of blood after a tonsillectomy. This allows the nurse to monitor the situation and determine if the bleeding is worsening or if it resolves on its own. It is important to keep the child calm and avoid any actions that could exacerbate the bleeding.
Choice C rationale
Encouraging the child to cough can increase the risk of further bleeding. Coughing can dislodge clots and cause additional trauma to the surgical site. It is important to keep the child calm and avoid actions that could worsen the bleeding.
Choice D rationale
Suctioning the back of the throat can cause additional trauma to the surgical site and increase the risk of bleeding. It is important to avoid invasive procedures and continue to assess for bleeding. If the bleeding worsens, further medical intervention may be necessary.
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