The practical nurse (PN) is caring for a child who was admited after experiencing a generalized tonic-clonic seizure. When witnessing the child begin the seizure, what should the PN implement immediately? (Select all that apply)
Observe the progression of the seizure
Hold the extremities close to the body
Insert a tongue blade between the teeth
Pad the side rails with pillows
Loosen clothing around the neck
Correct Answer : A,D,E
The correct answers are:
a) Observe the progression of the seizure.
- Pad the side rails with pillows.
- Loosen clothing around the neck.
Explanation: During a generalized tonic-clonic seizure, it is important for the practical nurse (PN) to prioritize the safety and well-being of the child. The correct actions to implement immediately are:
a) Observe the progression of the seizure: The PN should closely observe the seizure to gather important information that can be helpful for medical professionals in assessing the seizure's characteristics and duration.
- Pad the side rails with pillows: Padding the side rails of the bed with pillows helps to prevent the child
from injuring themselves by hitting the side rails during the seizure.
- Loosen clothing around the neck: Loosening any tight clothing around the child's neck helps to ensure adequate breathing and prevent any constriction or discomfort during the seizure.
- Hold the extremities close to the body: This action is not recommended during a seizure as it may increase the risk of injury to the child or the PN.
- Insert a tongue blade between the teeth: It is not recommended to insert any object, including a tongue blade, between the teeth of a person experiencing a seizure. This can cause injury to the person's mouth or teeth and is no longer considered an appropriate intervention for seizures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
The nurse should consider the patient's physical abilities and limitations when planning recreational activities because this information is crucial for ensuring the safety and appropriateness of the activities. For example, a patient with limited mobility may benefit from activities that can be done in a seated position, while a patient with greater physical abilities may be able to engage in more active pursuits.
Choice B rationale:
The patient's cognitive abilities and limitations should also be taken into account when planning activities. Some patients may have cognitive impairments that require simpler, more straightforward activities, while others may be able to participate in more complex or intellectually stimulating options. This ensures that the activities are enjoyable and suitable for the individual's cognitive capacity.
Choice C rationale:
Considering the patient's interests and preferences is essential to make the recreational activities meaningful and enjoyable. It is important to involve patients in activities they find interesting and pleasurable, as this can have a positive impact on their emotional and psychological well-being during the rehabilitation process.
Choice E rationale:
The patient's cultural and religious background is an important consideration when planning activities. Some activities may be more or less acceptable to individuals from different cultural or religious backgrounds. It's essential to respect cultural and religious preferences to ensure that the activities do not cause discomfort or offense to the patients.
Choice D rationale:
The patient's age and gender are not the primary factors to consider when selecting appropriate activities for individuals in a rehabilitation and restorative care setting. Age and gender do not necessarily determine a person's interests, physical abilities, or cognitive limitations. Therefore, they are not as relevant as the other factors listed in this context.
Correct Answer is D
Explanation
The correct answer and explanation is:
d) Massage the fundus and avoid direct pressure on the cesarean incision.
This is the best action to take for a client who experiences a sudden gush of vaginal blood and clots after a
cesarean section. Massaging the fundus helps to stimulate uterine contractions and reduce bleeding.
Avoiding direct pressure on the incision prevents pain and wound dehiscence.
a) Insert an indwelling catheter to empty the bladder and contract the fundus.
This is not the first action to take for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Inserting an indwelling catheter requires a physician's order and may cause discomfort and infection. The client may already have a catheter in place after the surgery.
b) Check fundal consistency and continue to monitor the lochial flow amount.
This is not enough to do for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Checking fundal consistency and monitoring lochial flow are important, but they do not address the cause of bleeding or prevent further blood loss.
c) Return the client to bed and maintain bedrest until the lochial flow slows.
This is not appropriate for a client who experiences a sudden gush of vaginal blood and clots after a cesarean section. Returning the client to bed and maintaining bedrest may delay ambulation and increase the risk of thromboembolism. It also does not stop the bleeding or treat the underlying cause.
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