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","B","D"]
Explanation
A) Preventing further Urinary Tract Infections:
This is a relevant priority for patients with reflux. Vesicoureteral reflux (VUR) is a condition where urine flows backward from the bladder into the ureters and sometimes to the kidneys, increasing the risk of urinary tract infections (UTIs). Preventing UTIs is important because recurring infections can lead to more severe kidney problems and complications. Teaching patients and caregivers about hygiene, proper voiding techniques, and recognizing UTI symptoms is crucial to minimize the risk of infections.
B) Preventing kidney damage:
Preventing kidney damage is a significant priority for patients with reflux. If urine refluxes back into the kidneys, it can lead to kidney damage over time. This damage can affect kidney function and potentially lead to chronic kidney disease. Monitoring kidney function, managing UTIs promptly, and considering medical or surgical interventions to correct reflux are all important strategies to prevent kidney damage.
C) The chances of needing brain surgery:
The chances of needing brain surgery are not directly related to reflux. Reflux primarily involves the urinary system, specifically the flow of urine from the bladder to the kidneys. Brain surgery is not a relevant consideration in the context of reflux or its management.
D) Antibiotic usage teaching with the presence of an infection:
This is an important aspect of care for patients with reflux who develop urinary tract infections. UTIs are common complications of reflux, and appropriate use of antibiotics is crucial to treat infections effectively and prevent further complications. Teaching patients and caregivers about the importance of completing prescribed antibiotic courses, recognizing signs of infection, and adhering to medical advice is essential to manage UTIs in the presence of reflux.
Correct Answer is A
Explanation
A. Elevate the head of the bed 15 to 30 degrees with head maintained a midline position.
Correct Explanation: This intervention is appropriate for a child with an acute head injury.
Explanation: Elevating the head of the bed helps reduce intracranial pressure by facilitating venous drainage from the head. However, it's important to keep the head in a midline position to prevent neck flexion, which can obstruct venous flow. Elevating the head 15 to 30 degrees is a standard approach for managing intracranial pressure in patients with head injuries.
B. Maintain an active stimulating environment.
Incorrect Explanation: Maintaining an active stimulating environment is not suitable for a child with an acute head injury.
Explanation: A child with an acute head injury should be in a quiet and calm environment. Overstimulation can worsen the condition by increasing intracranial pressure. It's important to minimize stimuli to allow the brain to heal.
C. Perform active chest percussion and suctioning every 1 to 2 hours.
Incorrect Explanation: Chest percussion and suctioning are not relevant interventions for an acute head injury.
Explanation: Active chest percussion and suctioning are typically used to manage respiratory conditions. While maintaining good respiratory function is important for overall patient care, it's not a primary intervention for an unconscious child with a head injury.
D. Instruct child on performing active range of motion.
Incorrect Explanation: Instructing the child on performing active range of motion is not appropriate for an unconscious child with a head injury.
Explanation: An unconscious child cannot actively perform range of motion exercises. Additionally, it's not a priority intervention in the acute phase of head injury management.
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