A nurse is collecting data from a client who reports feeling stress. Which of the following should the nurse identify as an external stressor?

Turn the child on to their side

When a child is experiencing a tonic-clonic seizure, the priority is to ensure their safety and protect their airway. Turning the child onto their side helps to prevent aspiration and maintain an open airway by allowing any saliva or fluids to drain out of the mouth. This position also helps to minimize the risk of injury.

The other options are incorrect:

Restraining the child's upper extremities in (option A) is not recommended during a seizure as it can potentially cause harm to the child or others around them.

Placing a padded tongue blade in the child's mouth in (option C) is an outdated practice that is no longer recommended. It can cause injury and is not necessary during a seizure.

Placing a pillow under the child's head in (option D) is generally not recommended during a seizure. It can interfere with the positioning of the head and may compromise the airway. The focus should be on maintaining an open airway and preventing injury, which is achieved by turning the child onto their side.

When a nurse encounters a client who has fallen, the immediate priority is to assess the client's condition and ensure their safety. By measuring the client's vital signs, the nurse can gather important information about the client's overall well-being, such as heart rate, blood pressure, respiratory rate, and oxygen saturation. This assessment helps determine if there are any immediate medical concerns resulting from the fall, such as injury or shock, that require prompt attention.
The other options listed are also important but should be addressed after the initial assessment and safety measures:
A. Notify the client's provider: After assessing the client's condition, if there are significant injuries or concerns identified, the nurse should promptly notify the client's provider to seek further medical guidance and intervention.
C. Complete an incident report: Reporting the fall incident is an essential part of ensuring quality and safety in healthcare. However, it is not the first action the nurse should take. The immediate focus should be on the client's assessment and safety. Completing an incident report can be done once the client's immediate needs are addressed.
D. Document the fall in the client's medical record: Documenting the fall in the client's medical record is important for maintaining accurate and comprehensive documentation. However, it should be done after the client's assessment, vital sign measurement, and any necessary interventions have been carried out.