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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A. Insomnia: Infants with increased ICP are more likely to be lethargic than to have insomnia.
B. Positive Babinski reflex: A positive Babinski reflex is normal in infants under 2 years and does not indicate ICP.
C. Bulging fontanel: A bulging fontanel is a classic sign of increased ICP due to the accumulation of fluid or swelling inside the skull.
D. Low-pitched cry: Infants with ICP typically have a high-pitched cry, not a low-pitched one.
Correct Answer is C
Explanation
A. Cough: A cough is more commonly associated with respiratory infections, not meningitis.
B. Joint pain: Joint pain is not a primary symptom of meningitis but may occur in other conditions.
C. Fever: Fever is a hallmark symptom of meningitis, reflecting the body’s immune response to infection.
D. Abdominal pain: Abdominal pain is not typically associated with meningitis.