In caring for a client who requires seizure precauons, the praccal nurse (PN) should ensure the ready availability of equipment to perform which procedure?

Sucon the trachea.

Insert a urinary catheter.

Apply so restraints.

Insert a nasogastric tube.

Answer and Explanation

The Correct Answer is A

Seizure precauons are measures taken to protect a client who is at risk of having a seizure, which is a sudden and abnormal electrical acvity in the brain that can cause changes in behavior, movement, sensaon, or consciousness. Seizure precauons include providing a safe environment, monitoring the client's vital signs and neurological status, administering anconvulsant medicaons, and documenng the onset, duraon, and characteriscs of any seizure acvity³.

One of the potenal complicaons of a seizure is aspiraon, which is the inhalaon of foreign material into the lungs, such as saliva, vomit, or food. Aspiraon can cause choking, pneumonia, or respiratory distress. To prevent or treat aspiraon, the praccal nurse (PN) should ensure the ready availability of equipment to perform suconing of the trachea, which is the tube that connects the mouth and nose to the lungs. Suconing of the trachea involves inserng a catheter through the nose or mouth into the trachea and applying negave pressure to remove any secreons or debris from the airway.

Therefore, opon A is the correct answer, while opons B, C, and D are incorrect.

Opon B is incorrect because inserng a urinary catheter is not related to seizure precauons or aspiraon prevenon.

Opon C is incorrect because applying so restraints may not be necessary or appropriate for a client who requires seizure precauons, as they may interfere with the natural movements of the seizure or cause injury to the client.

Opon D is incorrect because inserng a nasogastric tube is not related to seizure precauons or aspiraon prevenon.

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Correct Answer is D

Explanation

- Child abuse is the intentional or neglectful physical, emotional, or sexual harm or injury of a child by a parent, caregiver, or another person who has a relationship of trust or responsibility with the child. Child abuse can have serious and long-lasting consequences for the child's health, development, and well-being.

- The practical nurse (PN) has a legal and ethical duty to identify, report, and prevent child abuse. The PN should be alert for any signs and symptoms of child abuse, such as unexplained or inconsistent injuries, bruises, burns, fractures, or scars; behavioural changes, such as fear, anxiety, aggression, withdrawal, or depression; poor hygiene, nutrition, or growth; lack of supervision, medical care, or education; or sexualized behaviours or knowledge.

- The PN should also conduct a thorough and sensitive assessment of the child and the family situation, using open-ended questions, active listening, and a non-judgmental attitude. The PN should compare the history and physical findings of the child with the expected developmental milestones and normal variations for the child's age and stage. The PN should also document any relevant information in an objective and factual manner.

- When the mother of a school-aged boy tells the PN that he fell out of a tree and hurt his arm and shoulder, the PN should assess the child's injury and compare it with the mother's explanation. The most significant indicator of possible child abuse in this scenario is if the injury description by the mother varies from the child's version. This may suggest that the mother is lying or covering up the true cause of the injury, which may be intentional or accidental harm by herself or someone else. A discrepancy between the mother's and the child's stories may also indicate that the child is afraid or coerced to hide the truth about the abuse.

- Therefore, option D is the correct answer, while options A, B, and C are incorrect.

- Option A is incorrect because the child looking at the floor when answering the nurse's questions may not be a sign of abuse, but rather a sign of shyness, embarrassment, pain, or discomfort.

Option B is incorrect because the mother describing in detail what she did for her injured child may not be a sign of abuse, but rather a sign of concern, care, or guilt.

Option C is incorrect because the abrasions on the child's arms, legs, and chest having healed may not be a sign of abuse, but rather a sign of normal wound healing or previous accidents.

A. Consensual pupillary constriction present. B. Nystagmus present with pupillary focus. C. Pupils reactive to accommodation. D. Peripheral vision intact.

Correct Answer is C

Explanation

Accommodation refers to the ability of the eyes to adjust and focus on objects at diﬀerent distances. When a client's pupils constrict as they change focus from a far object to a near object, it indicates that their pupils are reacting appropriately to accommodate the change in focus.

To document this finding accurately, the practical nurse (PN) should document "Pupils reactive to accommodation." This statement captures the observation that the pupils are constricting in response to the client changing their focus from a far object to a near object. It indicates normal pupillary response and accommodation.

Let's brieﬂy evaluate the other options:

a) Consensual pupillary constriction present.

Consensual pupillary constriction refers to the simultaneous constriction of both pupils when light is shone into one eye. This finding is not directly related to accommodation or the client's change in focus.

Therefore, it is not the appropriate documentation for the given scenario.

b) Nystagmus present with pupillary focus.

Nystagmus refers to involuntary eye movements that can aﬀect the alignment and focus of the eyes. The presence of nystagmus is not mentioned in the scenario, and it is not directly related to the client's change in focus. Therefore, it is not the appropriate documentation for the given scenario.

d) Peripheral vision intact.

Peripheral vision refers to the ability to see objects outside the central visual field. While important for assessing visual function, it is not directly relevant to the observed pupillary response during accommodation. Therefore, it is not the appropriate documentation for the given scenario.

In summary, when a client's pupils constrict as they change focus from a far object to a near object, the practical nurse should document "Pupils reactive to accommodation" to accurately describe the observed pupillary response during the accommodation process.

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In caring for a client who requires seizure precauons, the praccal nurse (PN) should ensure the ready availability of equipment to perform which procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The mother of a school-aged boy tells the praccal nurse (PN) that he fell out of a tree and hurt his arm and shoulder. Which assessment should the praccal nurse (PN) note as the most significant indicator of possible child abuse?

Correct Answer is D

Explanation

The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?

Correct Answer is C

Explanation

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