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. A fracture from a bicycle injury is consistent with common childhood accidents and does not necessarily indicate maltreatment.
B. Small bruises on the shins of a toddler are typical as they learn to walk and play and are not necessarily a sign of maltreatment.
C. Frequent urinary tract infections in a young child can be a sign of sexual abuse or neglect and should be reported for further investigation. This pattern is concerning and warrants further evaluation by a healthcare provider.
D. Biting behavior in toddlers is relatively common and part of normal development. It does not necessarily indicate maltreatment.
Correct Answer is C
Explanation
A. Nasal discharge negative for glucose indicates that there is no cerebrospinal fluid (CSF) leakage, which is a positive sign. While it is important to note, it is not the priority in this situation.
B. A negative Babinski reflex is a normal finding in children older than 2 years. It does not indicate an acute issue and is not the priority.
C. Asymmetric pupils can be a sign of increased intracranial pressure or a serious brain injury, making this the priority finding. It requires immediate attention to prevent further complications.
D. A 2 cm scalp laceration, while needing medical attention, is not life-threatening and is not the highest priority compared to potential brain injury indicated by asymmetric pupils.
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