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 A
Explanation
A. Move the child into a side-lying position: This is the priority action to maintain an open airway, promote drainage of vomit, and reduce the risk of aspiration.
B. Remove the child's eyeglasses: While helpful to prevent injury, it is not the priority action during an active seizure.
C. Time the seizure: Timing is important to assess the duration and severity of the seizure, but it does not address immediate safety concerns like aspiration.
D. Place a pillow under the child's head: While this may prevent head injury, repositioning to a side-lying position to prevent aspiration is more critical.
Correct Answer is D
Explanation
A. Decreased pressure and cloudy cerebrospinal fluid with a high protein level. Meningitis usually causes increased intracranial pressure, not decreased.
B. Clear cerebrospinal fluid with a high protein and low glucose. Clear CSF is typically seen in viral meningitis, but bacterial meningitis more often causes cloudy CSF.
C. Cloudy cerebrospinal fluid with a low protein and low glucose. While glucose is low in bacterial meningitis, protein is typically elevated due to the infection.
D. Cloudy cerebrospinal fluid with a high protein and low glucose levels. This finding is consistent with bacterial meningitis, where the CSF is cloudy, protein is elevated due to inflammation, and glucose is low because bacteria consume glucose.