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 A
Explanation
Choice A rationale
Ignoring temper tantrums is an effective strategy for managing this behavior. By not giving attention to the tantrum, the child learns that this behavior will not achieve the desired outcome. This approach helps reduce the frequency and intensity of tantrums over time.
Choice B rationale
Restraining the child physically during a temper tantrum can escalate the situation and may cause injury to the child or the caregiver. It is not recommended as a strategy for managing temper tantrums.
Choice C rationale
Distracting the child by offering to play a game can be an effective strategy for preventing tantrums, but it is not the best approach once a tantrum has already started. Ignoring the tantrum is more effective in reducing the behavior over time.
Choice D rationale
Telling the child that temper tantrums are not acceptable may not be effective during the tantrum itself. The child is unlikely to be receptive to verbal reasoning during a tantrum. Ignoring the tantrum is a more effective strategy.
Correct Answer is D
Explanation
Choice A rationale
Encouraging the child to talk about the procedure is important for emotional support, but it is not the most critical assessment immediately after a cardiac catheterization. The priority is to monitor for potential complications.
Choice B rationale
Confirming to the child that the procedure has been completed is important for reassurance, but it is not the most critical assessment. The priority is to monitor for potential complications.
Choice C rationale
Gradually allowing the child to adapt to the lighted surroundings is not relevant to the immediate post-procedure care. The priority is to monitor for potential complications.
Choice D rationale
Checking pedal pulses frequently is the most important assessment after a cardiac catheterization via the femoral artery. It helps to ensure that there is adequate blood flow to the lower extremities and to detect any signs of arterial obstruction or complications at the catheter insertion site.