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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Destructive behavior can be associated with various psychological issues, including conduct disorders or exposure to domestic violence, but it is not a primary indicator of sexual abuse.
B. Withdrawn behavior is a common indicator of sexual abuse. Children who have experienced sexual abuse may exhibit social withdrawal, anxiety, depression, or reluctance to engage in normal activities due to fear or shame.
C. Manipulative behavior may be a learned response to stress or trauma, but it is not a direct indicator of sexual abuse. Other underlying issues, such as difficulty with attachment, may contribute to manipulative tendencies.
D. Perfectionistic behavior is often linked to high expectations from caregivers or anxiety disorders rather than sexual abuse. While trauma can contribute to perfectionism, it is not a key behavioral indicator.
Correct Answer is B
Explanation
A. Flushed skin is incorrect. Hypoglycemia typically causes pale, clammy skin due to the body's stress response. Flushed skin is more commonly associated with hyperglycemia.
B. Headache is correct. Hypoglycemia can cause neurological symptoms such as headache, dizziness, confusion, and irritability due to a lack of glucose available for brain function.
C. Fruity breath odor is incorrect. A fruity or acetone-like breath odor is a sign of diabetic ketoacidosis (DKA), which occurs with hyperglycemia, not hypoglycemia.
D. Thirst is incorrect. Increased thirst (polydipsiA. is a symptom of hyperglycemia due to excess glucose in the bloodstream drawing water out of the cells, leading to dehydration. Hypoglycemia does not typically cause excessive thirst.
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