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 C
Explanation
The correct answer is choice c. Ensure that the call bell is easily accessible to the client.
Choice A rationale:
Reassuring the client that someone will check on him hourly is supportive but does not directly address the immediate need for the client to call for assistance if he needs to use the bathroom during the night.
Choice B rationale:
Placing fresh water and a glass within reach is helpful for hydration but may increase the need to urinate, which could exacerbate the issue of urinary frequency at night.
Choice C rationale:
Ensuring that the call bell is easily accessible allows the client to quickly and safely request assistance if he needs to use the bathroom, reducing the risk of falls and ensuring timely help.
Choice D rationale:
Offering an evening snack before providing oral care is a good practice for comfort and nutrition but does not directly address the issue of urinary frequency or the need for nighttime assistance.
Correct Answer is B
Explanation
b) Observe how UAP obtains temperatures - Correct Answer
This is the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Observing how the UAP obtains temperatures will help the PN identify any errors or problems with the technique, equipment, or documentation. The PN can then provide feedback and guidance to the UAP to ensure accurate and reliable temperature measurements.
a) Demonstrate how to use the equipment.
This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Demonstrating how to use the equipment may be helpful, but it should be done after observing how the UAP obtains temperatures and determining the cause of the discrepancy.
c) Show UAP how to chart temperatures.
This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Showing UAP how to chart temperatures may be necessary, but it should be done after observing how the UAP obtains temperatures and verifying the accuracy of the data.
d) Return the thermometer for recalibration.
This is not the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Returning the thermometer for recalibration may be required, but it should be done after observing how the UAP obtains temperatures and ruling out any human or environmental factors that may affect the readings.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.