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 D
Explanation
A. "I promise I won't tell anyone about this.": This is inappropriate as nurses are mandated reporters and must inform authorities when abuse is suspected.
B. "Let's discuss what you have told me with your family members.": Involving the alleged abuser(s) directly can put the child at greater risk and is inappropriate.
C. "Your family is bad for doing this to you.": Judging or labeling the family is unprofessional and could make the child feel conflicted or guilty.
D. "It is not your fault that this happened.": This response reassures the child, alleviating feelings of guilt and fostering trust, while remaining supportive and professional.
Correct Answer is C
Explanation
A. Integumentary: Meningitis affects the central nervous system (CNS), not the skin, though a rash can sometimes appear with meningococcal meningitis.
B. Digestive: Digestive symptoms like nausea and vomiting may occur, but the primary system affected is the CNS.
C. Central Nervous: Meningitis is an inflammation of the meninges, which are protective coverings of the brain and spinal cord in the CNS.
D. Cardiopulmonary: Cardiopulmonary symptoms are not primary features of meningitis, though severe cases may affect vital systems indirectly.