Try Naxlex NCLEX-RN (Free-Trial)

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

A.

Place a pillow under the child's head.

B.

Clear the area of hazards.

C.

Position the child side-lying

D.

Loosen restrictive clothing

Answer and Explanation

The Correct Answer is C

A. Place a pillow under the child's head.

Explanation: While providing comfort is important, the priority in this scenario is to ensure the child's safety. Placing a pillow under the head can be considered after addressing immediate safety concerns.

B. Clear the area of hazards. 

Explanation: Correct Choice. Ensuring the area is clear of hazards is the nurse's priority. During a seizure, the child can experience uncontrolled movements, and having hazards around can lead to injuries. Clearing the area helps prevent harm. But priority is to position the child side lying.

C. Position the child side-lying.

Explanation: Correct Choice. Placing the child in a side-lying position helps prevent choking and aspiration due to vomiting during the seizure. It also minimizes the risk of airway obstruction and helps manage secretions. 

D. Loosen restrictive clothing.

Explanation: While loosening restrictive clothing can facilitate breathing, the priority in this situation is addressing safety concerns related to the seizure and vomiting. Ensuring a clear and safe environment takes precedence.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is A

Explanation

Fluid Requirement (mL/24 hours) = Weight (kg) × Fluid Requirement (mL/kg)

Given that the child weighs 70.4 pounds, we first need to convert this weight to kilograms (1 lb = 0.453592 kg):

Weight in kg = 70.4 lb × 0.453592 kg/lb ≈ 31.89 kg

Now, let's calculate the fluid requirement using the given choices:

A) 1740:

Fluid Requirement = 31.89 kg × 55 mL/kg = 1753.95 mL

B) 134056:

This number is significantly larger than any reasonable fluid requirement and is likely an error.

C) 2:

This value is far too low to represent the fluid requirements of a child.

D) 12:

This value is also too low to represent the fluid requirements of a child.

So, the correct answer is A) 1740 mL. The child's estimated daily fluid requirement would be around 1740 mL in a 24-hour period, based on a weight of 70.4 pounds.

Correct Answer is B

Explanation

A. Dizziness is always a sign of a concussion.

This statement is incorrect. While dizziness can be a symptom of a concussion, it is not always indicative of a concussion. There can be various causes of dizziness, and it is essential to consider other symptoms as well when assessing for a concussion.

B. Bike Helmet Safety

Explanation:

The correct answer to include as part of concussion/head injury prevention teaching to children and parents is "Bike helmet safety." This is because wearing a helmet while riding a bike or participating in other activities that involve head injury risks is crucial to prevent head injuries and concussions. Helmets provide protection to the head by absorbing impact energy and reducing the risk of skull fractures or traumatic brain injuries.

C. Normal fluid intake.

While staying hydrated is important for overall health, it is not directly related to concussion or head injury prevention teaching. This choice is unrelated to the topic.

D. Signs of autism.

Signs of autism are unrelated to concussion or head injury prevention teaching. This choice is not relevant to the topic at hand.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register