A nurse is caring for a school-age child who is having a tonic-clonic seizure. Which of the following actions should the nurse take?
Administer chlorothiazide.
Hold the child down.
Place the child in a prone position.
Time the episode.
The Correct Answer is D
Rationale:
A. Chlorothiazide is a diuretic and is not indicated during a seizure.
B. Holding the child down during a seizure can lead to injury and is not recommended. It's essential to ensure the child's safety by protecting the head from injury and removing any objects that could cause harm.
C. Placing the child in a prone position during a seizure can compromise their ability to breathe and is not recommended. Instead, the child should be placed in a safe position on their side to prevent aspiration.
D. Timing the duration of the seizure is crucial for medical management and documentation purposes. This action allows healthcare providers to assess the
severity of the seizure and determine the need for intervention or medication administration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
- A) Checking clothing for loose buttons is important because toddlers can easily remove and swallow small objects, which can lead to choking hazards.
- B) Adjusting the water heater temperature to 54° C (129.2° F) is not recommended as it poses a risk of scalding. Safe water temperatures for households with toddlers should be at or below 49° C (120° F).
- C) Placing screens on all windows is a crucial safety measure to prevent toddlers from falling out of open windows, which can lead to serious injuries or fatalities.
- D) Providing balloons for play is not advisable as uninflated or broken balloons can be a choking hazard for toddlers. It is one of the leading causes of choking deaths in children.
Correct Answer is B
Explanation
Rationale:
A. Rolling over from back to abdomen typically occurs around 4 to 6 months of age.
While it may be slightly delayed, it is not usually concerning at 5 months.
B. Head lag at 5 months is abnormal and may indicate weakness or poor muscle tone, warranting further evaluation by the healthcare provider.
C. Not all infants are able to hold a bottle at 5 months, and this finding alone may not be concerning.
D. The grasp reflex typically diminishes by 3 to 4 months of age, so it may not be present at 5 months. While it's a developmental milestone, its absence alone may not warrant immediate concern at this age.
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