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
b. Monitor the client for 15 min after meals.
d. Reinforce teaching about healthy eating during meals.
Explanation:
The correct answers are b. Monitor the client for 15 min after meals and d. Reinforce teaching about healthy eating during meals.
When planning care for a client with anorexia nervosa, it is important to focus on interventions that promote safety, nutritional rehabilitation, and psychological support.
Option a, encouraging the client to gain 2.3 kg (5 lb) per week, is not a realistic or healthy goal for weight gain in the context of anorexia nervosa. Rapid weight gain can be physically and psychologically overwhelming for the client and may reinforce disordered eating behaviors. Therefore, it is not an appropriate intervention.
Option c, weighing the client each morning after voiding, may contribute to obsessive monitoring of weight, which is a common feature of anorexia nervosa. Frequent weigh-ins can exacerbate anxiety and fixation on numbers, which are detrimental to the client's recovery. Therefore, it is not an appropriate intervention.
Option b, monitoring the client for 15 minutes after meals, is an important intervention. After meals, individuals with anorexia nervosa may engage in compensatory behaviors such as purging or excessive exercise. Monitoring the client for 15 minutes after meals allows for immediate identification of any concerning behaviors and provides an opportunity for therapeutic intervention, support, and redirection.
Option d, reinforcing teaching about healthy eating during meals, is also an important intervention. Although individuals with anorexia nervosa have distorted thoughts and beliefs related to food, providing education and support during meals can help them develop a healthier relationship with food and challenge their disordered eating behaviors and beliefs.
By recommending the interventions to monitor the client for 15 minutes after meals and reinforce teaching about healthy eating during meals, the nurse addresses the immediate post-meal period, promotes safety, provides support, and assists the client in their recovery journey. These interventions help ensure that the client is receiving appropriate care and support during meal times, which are critical for nutritional rehabilitation and challenging disordered eating behaviors.
Correct Answer is A
Explanation
A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates severe respiratory distress or failure. In this situation, the client's oxygenation is compromised, and immediate intervention is needed to ensure an open and unobstructed airway. The nurse should prioritize ensuring the client has a patent airway by assessing for any airway obstruction and taking appropriate measures to clear the airway if necessary. This may involve techniques such as the head tilt-chin lift or jaw thrust maneuver.
While administering oxygen, checking the client's pulse rate, and placing a pulse oximeter on the client's finger are all important interventions in managing respiratory distress, the first and most critical step is to establish a patent airway. Without a clear airway, the client's oxygenation cannot be adequately addressed, and other interventions may be ineffective. Once the airway is secured, the nurse can proceed with providing oxygen, assessing the client's vital signs, and monitoring oxygen saturation using a pulse oximeter.
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