A nurse is caring for a school-age child who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
Prevent movement of the child's extremities.
Administer magnesium sulfate to the child.
Put a tongue blade between the child's teeth.
Place a folded blanket under the child's head.
The Correct Answer is D
A. Prevent movement of the child's extremities is incorrect. Attempting to prevent movement during a tonic-clonic seizure is unsafe. The nurse should avoid restraining the child, as this can cause injury. The focus should be on ensuring safety during the seizure.
B. Administer magnesium sulfate to the child is incorrect. Magnesium sulfate is used for certain conditions, such as preeclampsia in pregnant women or seizures due to eclampsia, but it is not typically used to manage tonic-clonic seizures in children. Anticonvulsant medications or emergency interventions are more appropriate.
C. Put a tongue blade between the child's teeth is incorrect. Inserting a tongue blade or any object into the mouth during a seizure is dangerous, as it can lead to injury to the mouth, teeth, or airway. The nurse should not attempt to put anything in the child's mouth.
D. Place a folded blanket under the child's head is correct. The priority during a tonic-clonic seizure is to protect the child from injury. Placing a folded blanket or soft padding under the head helps prevent head trauma if the child falls to the ground during the seizure. The nurse should also ensure the environment is clear of sharp objects.
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Related Questions
Correct Answer is B
Explanation
A. Administering a regular diet is incorrect. While reintroducing a normal diet is important in managing diarrhea, it is not the priority in the acute phase. The toddler must first receive adequate hydration before resuming a regular diet.
B. Initiating IV fluid therapy is correct. In cases of severe dehydration or when the child cannot tolerate oral fluids, IV fluid therapy is the priority to restore fluid and electrolyte balance. Acute diarrhea can quickly lead to dehydration, making fluid replacement the most critical intervention.
C. Administering IV antibiotics is incorrect. Most cases of acute diarrhea in children are viral and do not require antibiotics. Even in bacterial cases, antibiotics are not always indicated unless the child has a severe infection or complications.
D. Initiating oral rehydration therapy is incorrect as the priority action. Oral rehydration therapy (ORT) is preferred for mild to moderate dehydration, but if the toddler is unable to tolerate oral fluids or has severe dehydration, IV fluids are the first-line treatment.
Correct Answer is C
Explanation
A. Nasal discharge negative for glucose. Nasal discharge negative for glucose suggests that the child likely does not have cerebrospinal fluid (CSF) leaking from the nose, which would be concerning for a basilar skull fracture. This is a less urgent finding compared to asymmetric pupils.
B. Negative Babinski reflex. A negative Babinski reflex is a normal finding in children over the age of 2, and thus it is not an urgent concern in this case.
C. Asymmetric pupils. This is the priority. Asymmetric pupils could be a sign of increased intracranial pressure or brain injury, which requires immediate intervention. It may indicate a serious condition, such as a brain hemorrhage or concussion, that requires urgent medical attention.
D. 2 cm (0.8 in) scalp laceration. While a scalp laceration may require suturing, it is not as urgent as asymmetric pupils, which could indicate a life-threatening condition. The laceration can be addressed after ensuring that there is no neurological emergency.
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