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 C
Explanation
Choice A rationale
Keeping the child flat and applying pressure to the bridge of the nose is not effective for managing a nosebleed. The child should be in an upright position to reduce blood flow to the nose and prevent swallowing blood.
Choice B rationale
Turning the child’s head to the side and pressing on the nasal ridge is not the recommended approach for managing a nosebleed. The child should be in an upright position with pressure applied to the sides of the nose.
Choice C rationale
Sitting the child upright and applying pressure to the sides of the nose is the correct action. This position helps to reduce blood flow to the nose and applying pressure helps to stop the bleeding.
Choice D rationale
Elevating the head of the bed slightly and applying pressure to the forehead is not effective for managing a nosebleed. The child should be in an upright position with pressure applied to the sides of the nose to stop the bleeding. .
Correct Answer is A
Explanation
Choice A rationale
High fever is a common finding in children experiencing sickle cell crisis. The crisis is often triggered by infections, which can cause fever. The sickled red blood cells can block blood flow, leading to tissue ischemia and necrosis, which can also contribute to fever.
Choice B rationale
Bradycardia, or a slow heart rate, is not typically associated with sickle cell crisis. The crisis usually causes an increased heart rate due to pain and the body’s stress response.
Choice C rationale
Constipation is not a common finding in sickle cell crisis. The primary symptoms are related to pain and vaso-occlusion, which can cause severe pain and other complications.
Choice D rationale
Decreased respiratory rate is not a typical finding in sickle cell crisis. The crisis can cause respiratory distress due to pain and hypoxia, leading to an increased respiratory rate.