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?
Place a pillow under the child's head.
Clear the area of hazards.
Position the child side-lying
Loosen restrictive clothing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: Correct Choice. Shaking or feeling shaky is a common symptom of low blood glucose levels, also known as hypoglycemia. When blood sugar drops too low, the body releases adrenaline, causing shaking or trembling. This response is indicative of an understanding of hypoglycemia symptoms.
B. "My son might have nausea and vomiting with hypoglycemia."
Explanation: Nausea and vomiting are not typical symptoms of hypoglycemia (low blood sugar). They are more commonly associated with hyperglycemia (high blood sugar) or other conditions. This statement is not accurate in the context of hypoglycemia.
C. "Sweating can occur with hyperglycemia."
Explanation: Sweating is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia (high blood sugar). When blood sugar levels drop too low, the body can respond with sweating as part of the adrenaline release. Sweating is not a typical symptom of hyperglycemia.
D. "The onset of low blood glucose usually occurs slowly."
Explanation: The onset of low blood glucose (hypoglycemia) can vary. It can occur suddenly, especially if the individual takes too much insulin or diabetes medication, leading to a rapid drop in blood sugar. The correct understanding is that the onset of low blood glucose can be rapid and not always slow.
Correct Answer is A
Explanation
A) Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are available.
Explanation: This statement is true. Vaccinations to prevent certain types of bacterial meningitis are available. Pneumococcal and Haemophilus influenzae type B (Hib) vaccines are included in routine childhood immunization schedules to protect against the bacteria that can cause meningitis and other serious infections. These vaccines have significantly reduced the incidence of bacterial meningitis in infants and children.
B) Often a genetic predisposition to meningitis is found.
Explanation: This statement is generally false. While there may be some genetic factors that influence susceptibility to infections, including meningitis, genetic predisposition is not a primary consideration when discussing the risk of meningitis. Meningitis is more commonly caused by bacterial or viral infections, and genetic predisposition is not a significant factor in its occurrence.
C) Meningitis rarely occurs during infancy.
Explanation: This statement is false. Meningitis can occur in infants, including newborns. In fact, infants are one of the age groups at higher risk for meningitis due to their underdeveloped immune systems and susceptibility to infections. Bacterial meningitis, in particular, can be severe and life-threatening in infants.
D) Vaccination to prevent all types of meningitis is now available.
Explanation: This statement is not entirely accurate. While vaccinations are available to prevent certain types of bacterial meningitis (such as pneumococcal and Hib meningitis), there is no single vaccine that can prevent all types of meningitis. Meningitis can be caused by various bacteria, viruses, and other pathogens, and the vaccines target specific ones. It's important for caregivers to ensure that their infants receive recommended vaccines to protect against the most common causes of meningitis.
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