A nurse is reinforcing teaching about home care with the parents of a child who has a seizure disorder. Which of the following instructions should the nurse include?
Call EMS if a seizure lasts 5 min or more.
Restrain the child at the onset of the seizure.
Offer the child a bubble bath every evening.
Place the child in a prone position during the seizure.
The Correct Answer is A
A. This is the correct answer. Seizures lasting longer than 5 minutes can be indicative of status epilepticus, a medical emergency requiring immediate intervention.
B. Restraint during a seizure can cause injury to the child and is not recommended. Instead, it's important to ensure the child's safety by removing nearby objects and gently guiding them to the floor if possible.
C. Offering a bubble bath every evening is not relevant to seizure care and does not contribute to the child's safety or well-being.
D. Placing the child in a prone position during a seizure can obstruct the airway and increase the risk of aspiration. The child should be placed in a lateral recumbent position to maintain an open airway and prevent injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A suction device is necessary for the nasogastric tube insertion procedure to remove gastric contents and ensure the tube is correctly placed in the stomach.
B. An infusion pump is not typically required for nasogastric tube insertion.
C. A disposable feeding bag is used for enteral feeding and is not directly related to the insertion of a nasogastric tube.
D. Sterile gloves are not typically used during nasogastric tube insertion, as it is a clean procedure rather than a sterile one.
Correct Answer is A
Explanation
A. A decreased level of consciousness and vomiting may indicate a potentially serious condition such as increased intracranial pressure, electrolyte imbalance, or metabolic disorder. Immediate assessment and intervention are necessary to determine the cause and provide appropriate treatment.
B. Cellulitis accompanied by a low-grade fever is concerning but may not require immediate attention compared to a decreased level of consciousness and vomiting.
C. A pain rating of 7 after receiving analgesia 30 minutes ago is important to address, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
D. A blood glucose level of 160 mg/dL in a client with type 2 diabetes mellitus may require monitoring and intervention, but it may not be as urgent as assessing a client with a decreased level of consciousness and vomiting.
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