Upon finding a school-age child having a seizure, what should be the nurse’s first action after lowering the client to the floor?

Turn the client to a lateral position.

Administer an anticonvulsant medication.

Apply oxygen by nasal cannula.

Check the client’s oxygen saturation.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The first action a nurse should take upon finding a school-age child having a seizure is to ease the person to the floor and turn the person gently onto one side. This will help the person breathe and can prevent injury.
Choice B rationale
Administering an anticonvulsant medication is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Choice C rationale
Applying oxygen by nasal cannula is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.
Choice D rationale
Checking the client’s oxygen saturation is not the immediate first action a nurse should take upon finding a child having a seizure. The first priority is to ensure the child’s safety by easing them to the floor and turning them onto their side.

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Correct Answer is B

Explanation

The correct answer is choice B: Instruct the parent to avoid pressing on the abdominal area.

Rationale for each choice:

Choice A: Schedule the child for an abdominal ultrasound. While an ultrasound may be necessary for further diagnosis, it is not the immediate priority. The child’s symptoms suggest a possible Wilms’ tumor, a type of kidney cancer that primarily affects children. An ultrasound can help confirm this diagnosis, but it should not be the first action.
Choice B: Instruct the parent to avoid pressing on the abdominal area. This is the correct answer. If the child has a Wilms’ tumor, pressing on the abdominal area could potentially cause the cancer to spread. Therefore, it is crucial to avoid any unnecessary pressure on the abdomen until further medical evaluation can be performed.
Choice C: Determine if the child is having pain. While assessing for pain is an important part of nursing care, it is not the immediate priority in this situation. The child’s symptoms need urgent medical attention, and assessing for pain will not provide the necessary information to guide immediate care.
Choice D: Obtain a urine specimen for a urinalysis. Although a urinalysis can provide valuable information about a patient’s health, it is not the immediate priority in this situation. The child’s symptoms suggest a possible Wilms’ tumor, which requires immediate medical attention. A urinalysis may be part of the diagnostic process, but it should not be the first action taken.

A. Rapid respirations B. Diminished reflexes C. Acetone breath D. Diaphoresis

Correct Answer is D

Explanation

Choice A rationale
Rapid respirations are not typically a manifestation of hypoglycemia. They are more commonly associated with conditions that cause metabolic acidosis, such as diabetic ketoacidosis.
Choice B rationale
Diminished reflexes are not a typical manifestation of hypoglycemia. They may be seen in conditions affecting the nervous system.
Choice C rationale
Acetone breath is not a manifestation of hypoglycemia. It is a sign of ketoacidosis, which is a complication of hyperglycemia, not hypoglycemia.
Choice D rationale
Diaphoresis, or sweating, is a common symptom of hypoglycemia. The body produces sweat as part of the sympathetic nervous system’s response to hypoglycemia.

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Upon finding a school-age child having a seizure, what should be the nurse’s first action after lowering the client to the floor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a toddler whose parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse’s priority?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?

Correct Answer is D

Explanation

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