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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Blood cultures are typically used to detect systemic infections or bacteremia, not Clostridium difficile, which is a bacterial infection primarily affecting the intestines.
B. A stool specimen for culture is the appropriate diagnostic test when C. difficile is suspected, as it can confirm the presence of the bacteria responsible for the infection. The stool test detects toxins A and B, which are produced by C. difficile and cause severe diarrhea.
C. The term "C. diff test" is too vague and does not specify a standard laboratory procedure. The correct test involves stool culture or toxin detection.
D. A stool test for occult blood checks for hidden blood in the stool, which may indicate gastrointestinal bleeding but does not diagnose C. difficile.
Correct Answer is C
Explanation
A. Constipation is incorrect. Hypocalcemia is more likely to cause neuromuscular excitability, including muscle spasms and cramps, rather than constipation. Constipation is more commonly associated with hypercalcemia.
B. Elevated blood pressure is incorrect. Hypocalcemia does not typically cause hypertension. Instead, it can lead to hypotension in severe cases.
C. Muscle tremors is correct. Hypocalcemia increases neuromuscular excitability, leading to symptoms such as muscle tremors, cramps, tetany, and positive Chvostek’s and Trousseau’s signs. These symptoms occur due to the role of calcium in nerve conduction and muscle contraction.
D. Tinnitus is incorrect. Hypocalcemia does not typically cause tinnitus (ringing in the ears). Tinnitus is more commonly associated with conditions affecting the auditory system, such as ototoxicity or Ménière’s disease.
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