A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure?
Clear the area of hard objects.
Minimize movement of the limbs.
Insert a tongue blade between the teeth.
Place the child in a prone position.
The Correct Answer is A
Choice A reason: Clearing the area of hard objects is crucial to prevent injury during a seizure. It helps to ensure that the child does not hit or get hurt by any objects in the vicinity while experiencing convulsions.
Choice B reason: Minimizing movement of the limbs is not recommended as it can cause injury to the child. Instead, the child should be allowed to move freely without restraint to avoid causing harm to their joints or muscles.
Choice C reason: Inserting a tongue blade between the teeth is an outdated and dangerous practice. It can cause injury to the child's mouth or teeth and may lead to choking if the tongue blade breaks.
Choice D reason: Placing the child in a prone position is not advised as it can obstruct the airway. The child should be placed on their side in the recovery position to keep the airway clear and allow fluids to drain from the mouth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice Areason: Decreased urine output is not directly related to ventriculoperitoneal shunt displacement. It may indicate other issues such as dehydration or kidney problems.
Choice Breason: Increased sleeping is not a specific indicator of shunt displacement. While it may be a concern if there are significant changes in the child's sleep patterns, it is not a definitive sign of this complication.Choice C reason: Hyperactive bowel sounds are not associated with shunt displacement. They may indicate gastrointestinal issues but are not relevant to the function of a ventriculoperitoneal shunt.
Choice D reason: An elevated temperature can be an indicator of shunt displacement, as it may suggest an infection or other complications related to the shunt. Parents should be aware of this sign and seek medical attention if it occurs.
Correct Answer is D
Explanation
Choice A reason: This is not the correct instruction to include in the discharge teaching. Perform clean intermittent catheterization every 8 hours is a possible intervention for infants who have neurogenic bladder dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require catheterization. The nurse should assess the infant’s bladder function and teach the guardian how to perform catheterization if needed.
Choice B reason: This is not the correct instruction to include in the discharge teaching. Use a rectal thermometer to stimulate the passage of stool twice per day is a possible intervention for infants who have neurogenic bowel dysfunction due to spinal cord injury or spina bifida. However, not all infants who have myelomeningocele repair require rectal stimulation. The nurse should assess the infant’s bowel function and teach the guardian how to manage constipation or fecal incontinence if needed.
Choice C reason: This is not the correct instruction to include in the discharge teaching. Anticipate gradual loss of function in the lower extremities is a possible outcome for infants who have myelomeningocele repair, depending on the location and severity of the defect. However, the nurse should not assume that the infant will lose function in the lower extremities. The nurse should monitor the infant’s motor and sensory development and provide appropriate interventions to promote mobility and prevent complications.
Choice D reason: This is the correct instruction to include in the discharge teaching. Check toys and pacifiers for the presence of latex is an important precaution for infants who have myelomeningocele repair, as they are at risk of developing latex allergy due to repeated exposure to latex products during surgery and medical procedures. The nurse should teach the guardian how to identify and avoid latex-containing items and how to recognize and treat signs of allergic reaction.
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