A nurse is reinforcing teaching with a parent of a school-age child who has tonic-clonic seizures. Which of the following statements should the nurse make regarding care during a seizure?
You should offer your child sips of clear liquids.
You should gently restrain your child using both of your arms.
You should place your child's head on a pillow.
You should give rectal diazepam to your child at the onset of the seizure.
The Correct Answer is C
Choice A reason:
The nurse should not offer the child sips of clear liquids during a seizure. During a tonic-clonic seizure, the child's swallowing reflex may be impaired, and giving liquids could lead to aspiration or choking, causing further complications.
Choice B reason:
The nurse should not restrain the child during a seizure using both arms or any other means. Restraint can potentially lead to injury for both the child and the person attempting to restrain them. It is crucial to allow the child to move freely during the seizure to prevent harm.
Choice C reason:
Placing the child's head on a pillow is the correct choice. This positioning helps to protect the child's head from injury during the seizure. The pillow provides a cushioning effect, minimizing the risk of head trauma.
Choice D reason:
The nurse should not instruct the parent to give rectal diazepam to the child at the onset of the seizure unless specifically prescribed by the child's healthcare provider. Diazepam is a medication used to manage seizures, but its administration route and timing should be determined by the child's healthcare provider. Inappropriate use of medication can be dangerous and ineffective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The nurse should include the statement that "This test measures amniotic fluid volume” in the teaching about the biophysical profile (BPP). The rationale for this is that the BPP is a prenatal screening tool that assesses the well-being of the fetus. One of the components of the BPP is the measurement of amniotic fluid volume, which helps to evaluate fetal kidney function and overall fetal health.
Choice B reason:
The nurse should not include the statement about receiving Rh(D) immune globulin prior to the test because it is not directly related to the biophysical profile (BPP). Rh(D) immune globulin is given to Rh-negative pregnant women to prevent hemolytic disease of the newborn (HDN) if the fetus is Rh-positive. While this may be important information during pregnancy, it is not specific to the BPP.
Choice C reason:
The nurse should not include the statement that "This test is used to assess uterine activity” in the teaching about the BPP. The BPP is a test focused on evaluating fetal well-being and not uterine activity. Uterine activity is typically assessed through other methods, such as monitoring contractions during labor.
Choice D reason:
The correct answer is not Choice D. The nurse should not include the statement that "Your bladder needs to be full to perform this test” in the teaching about the BPP. This statement is incorrect because a full bladder is not necessary for the BPP. Instead, the BPP involves the use of ultrasound to assess fetal movements, breathing, muscle tone, and amniotic fluid volume, and a full bladder is not a requirement for this assessment.
Correct Answer is B
Explanation
Choice A reason:
The nurse should prioritize Choice B over Choice A as it is essential to first confirm the correct placement of the NG tube before proceeding with any other actions. If the tube is not correctly positioned, administering the enteral feeding can lead to potential complications, such as aspiration, which can be life-threatening. Therefore, it is crucial to ensure the NG tube's proper placement before moving forward with the feeding
Choice B reason:
This option takes precedence as verifying the NG tube's position is a fundamental step in the enteral feeding process. The nurse must use appropriate methods, such as X-ray or pH testing, to confirm that the tube is in the stomach and not in the respiratory tract or elsewhere. This verification ensures the safety and effectiveness of the feeding procedure and prevents potential harm to the child.
Choice C reason:
While checking the gastric residual volume (GRV) is an important step in some cases, it should be done after confirming the NG tube's proper placement (Choice B). GRV provides information about the amount of feeding left in the stomach and helps in assessing tolerance to the feeding. However, if the NG tube is misplaced, determining GRV becomes irrelevant as the feeding would not be going to the intended location.
Choice D reason:
Flushing the child's NG tube with sterile water is an appropriate step during the enteral feeding process but should be done after verifying the tube's position (Choice B). Flushing ensures that the tube is patent and free from any obstructions, allowing the feeding to pass through smoothly. However, again, if the NG tube is incorrectly positioned, flushing it would not address the underlying issue.
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