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 B
Explanation
The correct answer is Choice B.
Choice A rationale
Insulin should be administered subcutaneously, not intramuscularly. Rotating sites is important to prevent lipodystrophy, but the correct technique involves subcutaneous injection.
Choice B rationale
Drawing up the short-acting insulin into the syringe first is correct. This prevents contamination of the short-acting insulin vial with long-acting insulin, ensuring accurate dosing.
Choice C rationale
Wiping off the needle with an alcohol swab is not recommended. The needle should remain sterile, and only the top of the insulin vial should be wiped with an alcohol swab.
Choice D rationale
Administering insulin at a 30-degree angle is incorrect. Insulin should be administered at a 90- degree angle if the person can grasp 2 inches of skin, or at a 45-degree angle if only 1 inch of skin can be grasped.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale
Environment plays a significant role in a child’s growth and development, including factors like socioeconomic status, access to education, and living conditions. However, it can be altered to some extent.
Choice B rationale
Genetics is the largest factor impacting growth and development that cannot be altered. Genetic factors determine physical characteristics, susceptibility to certain diseases, and overall growth patterns.
Choice C rationale
Socialization influences a child’s development, including social skills and behavior. While important, it can be influenced and altered through various interventions.
Choice D rationale
Nutrition is crucial for growth and development, affecting physical and cognitive development. However, it can be modified through dietary changes and interventions.
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