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 B
Explanation
Choice A rationale:
Encouraging the client to exercise every day to eliminate bedtime wakefulness is not appropriate advice in this scenario. It oversimplifies the issue and may not address the underlying causes of the client's sleep difficulties. Additionally, excessive exercise close to bedtime may actually interfere with sleep.
Choice C rationale:
Asking the client for a description of the exercise schedule being followed is a reasonable action. It allows the nurse to gather information about the client's exercise routine and assess whether it might be contributing to the sleep difficulties. However, this alone may not fully address the client's concerns.
Choice D rationale:
Determining the amount of weight the client has lost since increasing activity is relevant to the client's overall health and progress toward weight loss goals, but it does not directly address the issue of sleep difficulties. Weight loss and improved sleep may not always have a direct cause-and-effect relationship.
Correct Answer is D
Explanation
Choice A rationale:
Providing information about the client's healthcare power of attorney is not the most critical piece of information to report in this situation. The immediate concern is the client's change in mental status and potential medical emergency.
Choice B rationale:
While the reason for the client's admission is important background information, it is not the most urgent information to report in this situation. The priority is addressing the client's acute change in mental status.
Choice C rationale:
The nurse should be aware of the client's currently prescribed medications, but this information does not take precedence over the client's sudden onset of confusion and agitation. Immediate action is needed to address the client's altered mental status.
Choice D rationale:
Increasing confusion and agitation in a client who recently underwent ORIF of the right femur is a significant change in condition and may indicate a medical emergency such as infection, delirium, or other complications. This information should be provided first to alert the healthcare provider to the client's immediate needs.
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