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?
Place a folded blanket under the child's head.
Put a tongue blade between the child's teeth.
Administer magnesium sulfate IM to the child.
Prevent movement of the child's extremities.
The Correct Answer is A
A. Placing a folded blanket or any soft object under the child's head helps to protect the head from injury during the seizure. Ensuring safety is a priority during a seizure.
B. Putting a tongue blade or any object between the child's teeth can cause injury to the child. It is no longer recommended to place anything in the mouth during a seizure.
C. Magnesium sulfate is not indicated for treating tonic-clonic seizures. The focus should be on maintaining safety and monitoring the seizure.
D. Preventing movement of the child's extremities can cause injury. Instead, the nurse should protect the child from harm and ensure the environment is safe.
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Related Questions
Correct Answer is C
Explanation
A. Mixing medication in a bottle of formula is not recommended as the infant may not finish the entire bottle, leading to incomplete dosage. It also changes the taste of the formula, which may cause feeding aversions.
B. Honey should not be given to infants under 1 year old due to the risk of botulism. It is not a suitable medium for mixing medication for young infants.
C. Placing the medication in an oral syringe allows for precise dosing and easy administration. It ensures that the infant receives the correct amount of medication.
D. Placing the medication in the back of the infant's throat using a dropper can cause gagging and aspiration. An oral syringe allows for better control and safer administration.
Correct Answer is B
Explanation
A. The sensor should be applied to a site where it can provide accurate readings, but not specifically to the fingernail.
B. Repositioning the probe every 2 hours helps prevent skin irritation and ensures accurate readings.
C. Warming the skin prior to probe placement is not necessary and is not standard practice unless the client has circulatory compromise.
D. Taping the wire to the palm of the hand is not necessary and may cause discomfort or interfere with accurate readings.
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