the nurse is caring for a 5 year old child with a history of seizures the child suddenly begins to have a tonic clonic seizure what should the nurse d
Logo

Nursing Elites

HESI RN

Pediatric HESI

1. When caring for a 5-year-old child with a history of seizures who suddenly begins to have a tonic-clonic seizure, what should the nurse do first?

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority action is to turn the child to the side. This helps maintain an open airway and prevents aspiration of secretions or vomitus. It also helps in keeping the airway clear and promotes safety during the seizure episode. Administering oxygen, inserting an oral airway, and starting an IV line are important interventions but should follow the initial step of positioning the child to prevent airway obstruction.

2. An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?

Correct answer: C

Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress. Administering morphine sulfate (Choice A) is not the priority in this case as it may cause further respiratory depression. Starting IV fluids (Choice B) may not address the immediate cyanosis and hyperpnea. Providing 100% oxygen by face mask (Choice D) can help with oxygenation but may not be as effective as placing the infant in a knee-chest position to improve blood flow dynamics.

3. The parents of a 10-year-old child with newly diagnosed type 1 diabetes are being taught by the nurse about managing their child’s condition. Which statement by the parents indicates they need further teaching?

Correct answer: B

Rationale: It is important for individuals with diabetes to manage their carbohydrate intake, including sugary foods and drinks, rather than completely avoiding them. Sugary foods should be consumed in moderation as part of a balanced diet to help maintain stable blood glucose levels.

4. A mother brings her 3-month-old infant to the clinic, concerned about frequent vomiting after feeding. The practical nurse (PN) suspects gastroesophageal reflux (GER). Which recommendation should the PN provide to the mother?

Correct answer: C

Rationale: The correct recommendation for reducing symptoms of gastroesophageal reflux (GER) in infants is to keep the infant upright for 30 minutes after feeding. This position helps prevent the backflow of stomach contents, alleviating symptoms of reflux. Placing the infant in a prone position or providing larger, less frequent feedings may worsen symptoms by increasing the likelihood of regurgitation. Offering only formula thickened with rice cereal is not the first-line intervention for GER and should not be recommended initially.

5. A 14-year-old client with type 1 diabetes is participating in a school sports event. The nurse provides education to the client about managing blood glucose levels during physical activity. Which statement by the client indicates a need for further teaching?

Correct answer: C

Rationale: The correct answer is C. Skipping the insulin dose when blood sugar is high before exercise can be harmful. It is essential to manage blood glucose levels carefully during physical activity, which may require adjustments to insulin doses but skipping doses is not recommended. Checking blood sugar before and after exercise (Choice A) helps in monitoring and managing blood glucose levels. Eating a snack before playing (Choice B) can help maintain blood sugar levels during physical activity. Carrying a fast-acting carbohydrate (Choice D) is important in case of low blood sugar during sports to quickly raise glucose levels. Therefore, the client needs further teaching on the importance of not skipping insulin doses even if blood sugar is high before exercise.

Similar Questions

A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
In a 7-year-old child with a history of asthma experiencing an acute asthma exacerbation and displaying wheezing and the use of accessory muscles to breathe, what is the nurse’s priority intervention?
When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?
What information should be reinforced with the mother of a child with ringworm (Tinea)?
When reviewing developmental changes with the parents of a 6-month-old infant, what information should the practical nurse reinforce?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses