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
Explanation
A. This finding requires immediate action, as it indicates that the client is not receiving the prescribed amount of oxygen, which can compromise the oxygenation and perfusion of the tissues. The PN should adjust the flowmeter to deliver 3 liters per minute of oxygen, and check for any leaks or kinks in the tubing.
The other options are not correct because:
B. The absence of a humidifier does not require immediate action, as it is not a critical component of the oxygen delivery system. A humidifier can help moisten the dry oxygen and prevent mucosal irritation, but it is not essential for oxygenation.
CThe supine position does not require immediate action, as it is not a contraindication for oxygen therapy. The client may prefer this position for comfort or rest, and it does not affect the oxygen delivery or uptake.
D . The snug fit of the cannula does not require immediate action, as it is not a problem for oxygen therapy. The cannula should fit snugly against the client's cheeks to prevent dislodgment or slippage, and it does not interfere with the oxygen flow or diffusion.
Correct Answer is A
Explanation
Choice A rationale:
Instructing the client to bring all medications, supplements, and herbs currently being taken to the next clinic appointment (Choice A) is the best course of action. This allows the healthcare provider to review the client's entire medication regimen, identify any potential interactions or duplications, and make appropriate adjustments. It promotes medication safety and ensures that the client receives the most effective and safe treatment.
Choice B rationale:
Using a medication reminder system (Choice B) is a helpful suggestion but does not address the issue of potential duplications or interactions between medications. While a reminder system can improve adherence, it does not provide a comprehensive solution to the problem of multiple prescriptions for the same indication.
Choice C rationale:
Making certain a family member knows the name and use of all medications currently being taken (Choice C) is a useful practice for medication safety but may not be sufficient to address the issue of multiple prescriptions. Relying solely on a family member's knowledge may lead to misunderstandings or omissions in the medication regimen.
Choice D rationale:
Do not take any over-the-counter drugs while taking medications prescribed by a healthcare provider (Choice D) is a relevant piece of advice for medication safety. However, it does not directly address the issue of multiple prescriptions for the same indication. It is essential for the client to have a complete and accurate record of all medications, both prescribed and over-the-counter, to ensure safe and effective treatment.
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