Nokea
You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)
- A. Bed in highest position
- B. Remove restrictive objects or clothing from patients' body
- C. Remove all pillows from the patient's head
- D. Oxygen and suction at bedside
- E. Padded bed rails
Correct Answer: B,D,E
Rationale: A. Bed in highest position: The height of the bed is not directly related to seizure precautions. B. Remove restrictive objects or clothing from patient's body: This is important to prevent injury during a seizure episode. C. Remove all pillows from the patient's head: While it's generally a good practice to remove pillows to prevent suffocation or obstruction, it's not specifically related to seizure precautions. D. Oxygen and suction at bedside: Oxygen and suction should be readily available to support the patient's respiratory status and clear any secretions or vomit during or after a seizure. E. Padded bed rails: Padded bed rails can help prevent injury if the patient thrashes or moves violently during a seizure.
You may also like to solve these questions
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.
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.
A nurse is caring for a child who has acute diarrhea and reports that he is thirsty. Which of the following fluids should the nurse give the child?
- A. Broth
- B. Apple juice
- C. Cherry gelatin
- D. Pedialyte
Correct Answer: D
Rationale: Broth: Broth is not typically recommended for children with acute diarrhea because it lacks the necessary electrolytes to adequately replace those lost through diarrhea. While it can help provide some fluids, it may not be sufficient for rehydration and could potentially worsen dehydration if electrolytes are not adequately replaced. Apple juice: While apple juice may seem like a hydrating option, it is not the best choice for children with acute diarrhea. Apple juice contains a high amount of sugar, which can draw water into the intestines and worsen diarrhea. Additionally, it lacks the necessary electrolytes needed for rehydration. Cherry gelatin: Cherry gelatin is not recommended for rehydrating a child with acute diarrhea. Like apple juice, it contains sugar, which can exacerbate diarrhea by drawing water into the intestines. Gelatin also lacks the electrolytes needed to replace those lost through diarrhea. Pedialyte: Pedialyte is the preferred choice for rehydrating a child with acute diarrhea. It is specifically formulated to replace lost fluids and electrolytes and is less likely to worsen diarrhea compared to sugary beverages like juice or gelatin. Pedialyte helps prevent dehydration by providing a balanced mixture of water, sugar, and electrolytes, making it an effective choice for managing diarrhea in children.
A nurse is reinforcing teaching about lice with the parents of a school-age child at a well-child visit. Which of the following information should the nurse include?
- A. Lice do not survive away from the host.
- B. Washing your child's hair daily will prevent lice.
- C. Encourage your child to avoid sharing hats with other children.
- D. Lice can jump from one child to another.
Correct Answer: C
Rationale: Lice do not survive away from the host.' - This statement is incorrect. Lice can survive away from the host (human scalp) for a limited period, usually up to 1-2 days. They may be found on items such as bedding, clothing, hats, or hair accessories. Therefore, proper cleaning and disinfection of these items are essential to prevent the spread of lice. 'Washing your child's hair daily will prevent lice.' - This statement is incorrect. While maintaining good hygiene is important, washing hair daily does not necessarily prevent lice infestation. Lice infestations occur through direct head-to-head contact with an infested person, not due to uncleanliness. Additionally, lice are more commonly found in clean hair rather than dirty hair. 'Encourage your child to avoid sharing hats with other children.' - This statement is correct. Sharing personal items such as hats, scarves, brushes, or hair accessories can facilitate the spread of lice from one person to another. Therefore, it's important to advise children not to share these items to reduce the risk of lice transmission. 'Lice can jump from one child to another.' - This statement is incorrect. Lice do not have the ability to jump or fly. They spread through direct contact with the hair or scalp of an infested person. However, they can crawl quickly from one person to another, especially when there is close contact, such as during play or when sharing personal items.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Place the child in a side-lying position.
- B. Restrain the child's arms.
- C. Elevate the child's legs on a pillow.
- D. Insert a padded tongue blade into the child's mouth.
Correct Answer: A
Rationale: Place the child in a side-lying position. This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs. Restrain the child's arms. Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure. Elevate the child's legs on a pillow. Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury. Insert a padded tongue blade into the child's mouth. Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.