A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse’s priority?
Loosen restrictive clothing.
Position the child side-lying.
Place a pillow under the child’s head.
Clear the area of hazards.
The Correct Answer is B
Choice A rationale
Loosening restrictive clothing can help ensure the child is comfortable and can breathe easily during a seizure. However, it is not the priority action. The primary concern during a tonic- clonic seizure is to maintain the child’s airway and prevent aspiration, especially if the child is vomiting.
Choice B rationale
Positioning the child side-lying is the priority action. This position helps maintain an open airway and allows any vomit or secretions to drain out of the mouth, reducing the risk of aspiration.
Choice C rationale
Placing a pillow under the child’s head can provide comfort and prevent head injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
Choice D rationale
Clearing the area of hazards is important to prevent injury during a seizure. However, it is not the priority action. The primary concern is to maintain the child’s airway and prevent aspiration.
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Correct Answer is D
Explanation
Choice A rationale
While some children may pull their ears when they have a cold, it is not a definitive sign of acute nasopharyngitis. Ear pulling can also indicate other issues such as ear infections.
Choice B rationale
Antibiotics are not typically prescribed for acute nasopharyngitis, as it is usually caused by a viral infection. Antibiotics are only used if there is a secondary bacterial infection.
Choice C rationale
Healthy children can have multiple colds per year, especially if they are exposed to other children in settings like daycare or school. It is not uncommon for children to have several colds annually.
Choice D rationale
A cough that accompanies a cold should not be suppressed as it helps clear mucus from the airways. Suppressing the cough can lead to mucus buildup and potential complications.
Correct Answer is D
Explanation
Choice A rationale
Temper tantrums are not a type of learning disability. They are a normal part of toddler development and are a way for toddlers to express frustration and assert independence.
Choice B rationale
Leaving the room while a tantrum is happening is not recommended. It is important for parents to stay calm and present, providing a safe environment for the child. Ignoring the tantrum while staying nearby can help the child learn to self-regulate.
Choice C rationale
Psychological consults are not typically necessary for temper tantrums. Temper tantrums are a normal part of development and usually decrease as the child learns to communicate and manage emotions better.
Choice D rationale
Temper tantrums are indeed the toddler’s attempt to gain control of a situation. Toddlers often have tantrums when they are unable to express their needs or when they are frustrated by their lack of control over their environment. Understanding this can help parents respond appropriately and support their child’s emotional development.