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A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Move the child into a side-lying position.
- B. Place a pillow under the child's head.
- C. Time the seizure.
- D. Remove the child's eyeglasses.
Correct Answer: A
Rationale: Move the child into a side-lying position: This action is crucial during a seizure with vomiting to prevent aspiration. Placing the child on their side helps ensure that any vomit can easily exit the mouth and reduces the risk of choking or aspiration into the lungs. Place a pillow under the child's head: While providing comfort is important, it is not the priority during a seizure with vomiting. Placing a pillow under the child's head might elevate the head slightly, but it doesn't address the risk of aspiration, which is the primary concern. Time the seizure: Timing the seizure is important for documentation and to monitor the duration of the seizure. However, it is not the priority during the active phase of the seizure, especially when vomiting is occurring. Remove the child's eyeglasses: Removing the child's eyeglasses is not a priority during a seizure with vomiting. While it's important to prevent injury, particularly to the eyes, during a seizure, the immediate concern is addressing the risk of aspiration caused by vomiting.
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A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Monitor the client's hemoglobin level
- B. Restrain the client's extremities
- C. Place the client in a prone position
- D. Record the time and length of the seizure
Correct Answer: D
Rationale: Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)
- A. Place a tongue depressor in the child's mouth.
- B. Restrain the child.
- C. Clear the area of hard objects.
- D. Loosen restrictive clothing.
- E. Place the child in a prone position
Correct Answer: C,
Rationale: A. Place a tongue depressor in the child's mouth: This is an incorrect action. Placing a tongue depressor or any other object in the child's mouth during a seizure can cause injury to the child's mouth, teeth, or airway. It may also increase the risk of choking. It's a common misconception that people can swallow their tongues during a seizure, but this is not true. It's important to keep the child's mouth clear of objects and allow the seizure to run its course. B. Restrain the child: This is also an incorrect action. Restraint can cause further injury to the child and increase agitation, which may worsen the seizure. It's important to allow the child to move freely during a seizure while taking steps to ensure their safety, such as clearing the area of objects and protecting the head from injury. C. Clear the area of hard objects: This is a correct action. Removing hard objects from the area helps prevent injury to the child during a seizure. Objects such as furniture corners or sharp items can pose a risk if the child thrashes or moves unpredictably during the seizure. D. Loosen restrictive clothing: This is also a correct action. During a seizure, it's important to ensure that the child's clothing is not too tight or restrictive. Loosening clothing, especially around the neck and chest area, helps ensure adequate airflow and prevents restriction of movement during the seizure. E. Place the child in a prone position: This is an incorrect action. Placing the child in a prone (face-down) position during a seizure can increase the risk of airway obstruction and make it more difficult for the child to breathe. Instead, the child should be placed on their side (recovery position) to help maintain an open airway and prevent aspiration if vomiting occurs.
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?
- A. Maintain seizure precautions.
- B. Document intake and output.
- C. Administer antibiotics when available.
- D. Reduce environmental stimuli.
Correct Answer: C
Rationale: Maintain seizure precautions: While seizures can occur as a complication of bacterial meningitis, maintaining seizure precautions is not the nurse's priority at this stage. Prompt administration of antibiotics to address the underlying infection takes precedence over seizure precautions. Document intake and output: Documenting intake and output is an important nursing responsibility, but it is not the priority when a child is suspected of having bacterial meningitis. The immediate priority is to initiate antibiotic therapy to treat the infection and prevent further complications. Administer antibiotics when available: Administering antibiotics is the priority in the care of a child with suspected bacterial meningitis. Antibiotics are crucial for treating the infection and preventing its progression to reduce the risk of serious complications such as brain damage or death. Reduce environmental stimuli: While reducing environmental stimuli can help manage symptoms and discomfort in a child with bacterial meningitis, it is not the priority at this time. Initiating antibiotic therapy is essential to address the underlying infection, which takes precedence over environmental stimuli reduction.
A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect?
- A. Maculopapular lesions between fingers and toes
- B. Inflamed area with white exudate
- C. Nonpruritic erythematous papule
- D. Rash with thick skin
Correct Answer: D
Rationale: Maculopapular lesions between fingers and toes: This finding is not typically associated with atopic dermatitis. Maculopapular lesions between the fingers and toes are more commonly seen in conditions like scabies or fungal infections. Inflamed area with white exudate: This finding is also not characteristic of atopic dermatitis. An inflamed area with white exudate may indicate a bacterial infection rather than atopic dermatitis. Nonpruritic erythematous papule: Atopic dermatitis often presents with erythematous (red) papules (small raised bumps) that are pruritic (itchy). However, the presence of nonpruritic lesions is less typical of atopic dermatitis. Rash with thick skin: This finding is consistent with atopic dermatitis. Chronic scratching and rubbing of the affected areas can lead to thickening of the skin (lichenification) in individuals with atopic dermatitis.
12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be?
- A. 24 lb 6 oz
- B. 20 lb 5oz
- C. 32 lb 8 0z
- D. 16 lb 4 oz
Correct Answer: A
Rationale: The nurse should expect the 12-month-old boy to weigh approximately 24 lb 6 oz (since 0.375 lb ≈ 6 oz).
So, around 24 lbs 6 oz is a normal expected weight at 12 months for a baby born at 8 lb 2 oz.