A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?
Apply oxygen by nasal cannula.
Turn the client to a lateral position.
Administer an anticonvulsant medication.
Check the client's oxygen saturation.
The Correct Answer is B
A. Apply oxygen by nasal cannula: Applying oxygen can be beneficial but is not the immediate priority during an active seizure. Protecting the airway comes first.
B. Turn the client to a lateral position: This action prevents aspiration by keeping the airway clear if the client vomits or has excessive secretions.
C. Administer an anticonvulsant medication: Medications may be necessary later, but immediate safety and airway protection take precedence.
D. Check the client’s oxygen saturation: Monitoring oxygen saturation is important but should follow positioning to ensure airway protection.
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Correct Answer is C
Explanation
A. The child is confused and cannot remember anything regarding the seizure: Postictal confusion is normal after a seizure and does not require emergency services.
B. The child fell at the onset of the seizure: Falls can occur with seizures, but unless there is a suspected injury or prolonged seizure activity, calling 911 is unnecessary.
C. The seizure lasts more than 5 minutes: A seizure lasting more than 5 minutes is considered status epilepticus and is a medical emergency requiring immediate intervention.
D. The child is sleepy and lethargic after the seizure: Postictal sleepiness is a common and expected phase after a generalized seizure.
Correct Answer is ["A","C","E"]
Explanation
A. Febrile episode: Fever is a common trigger for febrile seizures in children, especially between 6 months and 5 years.
B. Low blood lead levels: Elevated, not low, blood lead levels can increase the risk of seizures due to neurotoxicity.
C. Sodium imbalance: Both hyponatremia and hypernatremia can cause seizures by disrupting neuronal function.
D. Presence of diphtheria: Diphtheria does not directly increase the risk of seizures. Neurological complications are rare and secondary.
E. Hypoglycemia: Low blood sugar levels deprive the brain of energy, which can lead to seizures.