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
The correct answer is a. Call EMS if a seizure lasts 5 minutes or more.
Explanation:
When providing home care instructions for a child with a seizure disorder, it is important to educate the parents about appropriate actions during a seizure. Calling emergency medical services (EMS) if a seizure lasts 5 minutes or more is crucial because it may indicate a condition called status epilepticus, which is a prolonged seizure or a series of seizures without full recovery of consciousness between them. Status epilepticus is a medical emergency that requires immediate medical intervention.
Option b, restraining the child at the onset of a seizure, is not recommended. Restraint can potentially cause harm to the child and increase the risk of injury. It is advised to create a safe environment by removing any nearby objects that could cause injury and placing a pillow or cushion under the child's head to prevent head injury.
Option c, offering the child a bubble bath every evening, is not specifically related to seizure management. Bathing routines can be continued as long as they are safe and supervised. However, it is important to ensure the child's safety during bathing, such as providing adequate supervision to prevent drowning or injury.
Option d, placing the child in a prone position during a seizure, is not recommended. Placing the child in a prone position (face down) during a seizure can obstruct the airway and increase the risk of respiratory complications. The child should be placed on their side, in a recovery position, to facilitate drainage of saliva or other fluids and prevent choking.
Overall, the most important instruction for the parents is to recognize the signs of prolonged seizure activity and to seek immediate medical assistance by calling EMS if a seizure lasts 5 minutes or more.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The charge nurse should explain to the assistive personnel (AP) that one of the responsibilities of a licensed practical nurse (LPN) is providing direct client care. LPNs work under the supervision of registered nurses (RNs) and are trained to deliver basic nursing care to clients. This includes tasks such as administering medications, monitoring vital signs, dressing wounds, assisting with activities of daily living (ADLs), and reporting any changes in the client's condition to the RN.
The other options are not typically within the scope of practice for an LPN:
a. Coordinating client care: The coordination of client care is primarily the responsibility of the RN. While LPNs may contribute to the coordination of care by providing input and collaborating with the healthcare team, the overall coordination is usually managed by the RN.
c. Assessing a client's health status: Assessing a client's health status is a role primarily performed by RNs. LPNs may gather data and contribute to the assessment process, but the comprehensive assessment and interpretation of data is typically the responsibility of the RN.
d. Identifying specific client health problems: Identifying specific client health problems and formulating nursing diagnoses is part of the RN's role. LPNs may assist in collecting data and providing input, but the identification and formulation of nursing diagnoses are within the scope of practice of the RN.
Correct Answer is D
Explanation
When taking allopurinol, a medication commonly used to treat gout and prevent kidney stones, the nurse should instruct the client to monitor and report the manifestation of a skin rash with fever. Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening condition that can occur as a rare side effect of allopurinol. It is characterized by a widespread rash, often with fever, and can progress to involve the mucous membranes (e.g., mouth, eyes) and cause severe complications.
The other manifestations mentioned, such as diplopia (double vision), tinnitus with ear pain, and hyperreflexia (exaggerated reflexes), are not typically associated with Stevens-Johnson syndrome and should not be directly attributed to this condition. However, it's important for the client to report any unusual or severe symptoms to their healthcare provider for further evaluation and appropriate management.

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