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. "I know that my child will need to have a companion when swimming." This is a correct precaution to prevent drowning in case of a seizure.
B. "I will make my child wear a medical identification bracelet." This is correct to alert others in case of an emergency.
C. "I will need to give antiseizure medications when my child has a seizure." Antiseizure medications are typically administered as a preventive measure, not during a seizure. Emergency medications (e.g., rectal diazepam) may be used for prolonged seizures but are not routine for every seizure.
D. "I will have my child wear a bike helmet when riding a bike or skateboard." This is correct to protect the child from head injuries during activities.
Correct Answer is B
Explanation
A. Describing manifestations of the illness: Preschoolers lack the cognitive ability to describe symptoms in detail.
B. Relating fears to magical thinking: Magical thinking is characteristic of preschoolers, and they may associate illness with punishment or fantastical causes.
C. Awareness of body function: This is more typical of school-age children, not preschoolers.
D. Understanding cause of illness: Preschoolers do not have the cognitive development to understand illness causation fully.