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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Hirschsprung’s disease is characterized by inadequate motility of part of the intestine, resulting in a mechanical obstruction. This condition is caused by the absence of ganglion cells in the affected segment of the intestine, leading to a lack of peristalsis and subsequent obstruction.
Choice B rationale
Encopresis is a condition characterized by the repeated passage of feces into inappropriate places, such as clothing or the floor. It is not associated with inadequate motility of the intestine or mechanical obstruction.
Choice C rationale
Pyloric stenosis is a condition characterized by the narrowing of the pylorus, which leads to obstruction of the passage of food from the stomach to the small intestine. It is not associated with inadequate motility of the intestine.
Choice D rationale
Enterocolitis is an inflammation of the intestine and colon. It is not associated with inadequate motility of the intestine or mechanical obstruction.
Correct Answer is D
Explanation
Choice A rationale
Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.
Choice B rationale
Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.
Choice C rationale
Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.
Choice D rationale
Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.