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
Slightly yellow sclera, or jaundice, is a common finding in children with sickle cell anemia. The breakdown of sickled red blood cells leads to increased bilirubin levels in the blood, which can cause jaundice. This yellowing is often most noticeable in the sclera of the eyes. Jaundice is a result of hemolysis, a hallmark of sickle cell anemia, where red blood cells are destroyed faster than they can be produced.
Choice B rationale
Depigmented areas on the abdomen are not typically associated with sickle cell anemia. Sickle cell anemia primarily affects the blood and organs, leading to complications such as pain crises, anemia, and organ damage. Skin changes like depigmentation are not characteristic of this condition and may indicate other underlying issues.
Choice C rationale
Enlarged mandibular growth is not a common finding in sickle cell anemia. While children with sickle cell anemia may experience growth delays and skeletal abnormalities due to chronic anemia and bone marrow hyperactivity, mandibular enlargement is not a typical feature. Skeletal changes in sickle cell anemia are more likely to involve long bones and vertebrae.
Choice D rationale
Increased growth of long bones is not a characteristic finding in sickle cell anemia. In fact, children with sickle cell anemia may experience growth delays and shorter stature due to chronic anemia and the body’s increased demand for red blood cell production. The condition can lead to skeletal abnormalities, but these typically involve bone infarctions and deformities rather than increased growth.
Correct Answer is A
Explanation
Choice A rationale
Shaking the inhaler for 3 to 5 seconds ensures that the medication is properly mixed and ready for administration. This step is crucial for delivering the correct dose of medication.
Choice B rationale
Pressing down twice on the MDI canister is incorrect as it can lead to an overdose of medication. The correct technique involves pressing down once per inhalation.
Choice C rationale
Waiting 2 minutes between inhalations is not necessary. The recommended wait time between inhalations is usually 30 seconds to 1 minute.
Choice D rationale
Rinsing the mouth with mouthwash after inhaling the medication is not recommended. Instead, rinsing with water is advised to prevent oral thrush, especially when using corticosteroid inhalers.