The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.
Move furniture away from the child.
Place the child in a prone position.
Restrain the child.
Time the seizure
Insert a padded tongue blade in the child's mouth.
Stay with the child
Correct Answer : A,D,F
A.Move furniture away from the child.
Explanation: Creating a safe environment is important during a seizure. Moving furniture away from the child helps prevent injury.
B.Place the child in a prone position.
Explanation: Placing the child in a prone position (face down) is not recommended. The child should be placed on their side to allow for drainage of oral secretions and to prevent aspiration.
C. Restrain the child.
Explanation: Restraint is generally not recommended during a seizure, as it may cause injury to the child or the person providing care. Allow the seizure to run its course, and focus on keeping the environment safe.
D.Time the seizure.
Explanation: Timing the duration of the seizure is important for medical evaluation and management. Note the start and end times of the seizure.
E. Insert a padded tongue blade in the child's mouth.
Explanation: Inserting any object, including a padded tongue blade, into the child's mouth during a seizure is not recommended. This can lead to oral and dental injuries. Maintaining a clear airway and protecting the child from injury are priorities.
F. Stay with the child.
Explanation: Staying with the child provides support and ensures the child's safety during the seizure. It also allows the caregiver to observe and provide information to healthcare professionals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. It is inconclusive
Explanation: A serum phenylalanine level within the normal range is considered conclusive in ruling out phenylketonuria. Inconclusive results typically occur when there are issues with the sample or testing process.
B. It is negative
Explanation:
A serum phenylalanine level of 1 mg/dL (60.5 mcmol/L) in a 2-week-old infant is within the normal range. In the context of phenylketonuria (PKU) screening, a "negative" result means that the phenylalanine levels are within the expected range, and there is no evidence of phenylketonuria.
C. It requires rescreening at age 6 weeks.
Explanation: If the initial screening result is within the normal range, rescreening at age 6 weeks may not be necessary for phenylketonuria. The timing and need for rescreening may vary based on local protocols and individual patient factors.
D. It is positive
Explanation: A positive result for phenylketonuria would indicate that the serum phenylalanine levels are elevated, suggesting a potential diagnosis of PKU. In this case, the result is negative, meaning there is no evidence of PKU.

Correct Answer is A
Explanation
A. Orthopnea
Explanation:
Orthopnea refers to difficulty breathing that occurs when lying flat. In heart failure, fluid may accumulate in the lungs, leading to respiratory distress when the child is in a supine position. Orthopnea is a common symptom of heart failure in both adults and children.
B. Bradycardia
Explanation: Bradycardia (slow heart rate) is not a typical finding in heart failure. Heart failure often leads to compensatory mechanisms, including an increased heart rate (tachycardia), to maintain cardiac output.
C. Weight loss
Explanation: Weight loss is not a typical finding in heart failure. In fact, heart failure in children may lead to fluid retention and weight gain rather than weight loss.
D. Increased urine output
Explanation: Heart failure in toddlers is more likely to be associated with decreased urine output rather than increased urine output. Reduced cardiac output can result in decreased blood flow to the kidneys, leading to decreased urine production and potential fluid retention. Increased urine output is not a characteristic finding in heart failure.

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