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 B
Explanation
A. Detachment is the stage exhibited only in the hospital: Detachment can occur in other settings beyond the hospital. It is the final stage of separation anxiety and may manifest as a child appearing uninterested in caregivers, a coping mechanism to deal with prolonged separation.
B. Physical aggression such as kicking is an example of separation anxiety: Physical aggression, such as kicking or hitting, is a common behavior during separation anxiety, especially in younger children who cannot verbalize their emotions effectively.
C. It results in prolonged issues of adaptability: While separation anxiety may temporarily affect adaptability, most children overcome it as they grow. It does not inherently result in prolonged issues unless associated with other psychological conditions.
D. It is often observed in the school-aged child: Separation anxiety is most commonly observed in infants and toddlers (6 months to 3 years). By school age, children have typically developed coping mechanisms, though they may experience situational anxiety.
Correct Answer is A
Explanation
A. Speak slowly while facing the child: Facing the child helps them see lip movements and facial expressions, which aids communication.
B. Talk directly into the child's impaired ear: Shouting or talking directly into the ear is unhelpful and can distort sound further.
C. Stand above the child's eye level when speaking: Standing above the child can make communication difficult. The nurse should be at eye level to establish effective communication.
D. Speak loudly to the child: Speaking loudly can distort sound and is not helpful for a hearing-impaired child.