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What is the most appropriate nursing action when a

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What is the most appropriate nursing action when a child is in the tonic phase of ageneralized tonic–clonic seizure?a.Guide the child to the floor if standing and go for help.b.Turn the child’s body on the side.c.Place a padded tongue blade between the teeth.d.Quickly slip soft restraints on the child’s wrists.ANS: BPositioning the child on his side will prevent aspiration. It is inappropriate to leave the childduring the seizure. Nothing should be inserted into the child’s mouth during a seizure toprevent injury to the mouth, gums, or teeth. Restraints could cause injury. Sharp objects andfurniture should be moved out of the way to prevent injury.PTS:1DIF:Cognitive Level: Knowledge/RememberingREF:p. 1301 | Nursing Quality Alert BoxOBJ:Nursing Process: ImplementationMSC: Client Needs: Physiologic Integrity
24.After a tonic–clonic seizure, it would not be unusual for a child to displaya.irritability and hunger.b.lethargy and confusion.c.nausea and vomiting.d.nervousness and excitability.ANS: BIn the period after a tonic–clonic seizure, the child may be confused and lethargic. Somechildren may sleep for a period of time. The other manifestations are not normally seen after aseizure.PTS:1DIF:Cognitive Level: Knowledge/RememberingREF:p. 1296 | Box 52.5OBJ:Nursing Process: AssessmentMSC:Client Needs: Physiologic Integrity25.What should the nurse teach parents when the child is taking phenytoin (Dilantin) tocontrol seizures?a.The child should use a soft toothbrush and floss the teeth after every meal.b.The child will require monitoring of renal function while taking this medication.c.Dilantin should be taken with food because it causes gastrointestinal distress.d.The medication can be stopped when the child has been seizure free for 1 month.ANS: AA side effect of Dilantin is gingival hyperplasia. Good oral hygiene will minimize this adverseeffect. The child should have liver function studies because this anticonvulsant may causehepatic dysfunction, not renal dysfunction. Dilantin has not been found to causegastrointestinal upset. The medication can be taken without food. Anticonvulsants shouldnever be stopped suddenly or without consulting the physician. Such action could result inseizure activity.PTS:1DIF:Cognitive Level: Comprehension/UnderstandingREF:p. 1298 | Table 52.3OBJ:Nursing Process: ImplementationMSC:Client Needs: Physiologic Integrity26.The father of a newborn infant with myelomeningocele asks about the cause of thiscondition. What response by the nurse is most appropriate?a.“One of the parents carries a defective gene that causes myelomeningocele.”b.“A deficiency in folic acid in the father is the most likely cause.”c.“Offspring of parents who have a spinal abnormality are at greater riskfor myelomeningocele.”d.

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