The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?

Correct Answer: D

Rationale: In this situation, the nurse's priority is to provide a safe environment for the patient during the seizure. Inserting a padded tongue blade (Option A) is not recommended as it can cause more harm than good, such as dental injury. Restraint of the patient (Option B) during a seizure is also not recommended as it can lead to injury. Calling the operator to page for seizure assistance (Option C) may delay immediate intervention. The best course of action is for the nurse to clear the area of any objects that may injure the patient during the seizure and position the client safely. This will help prevent injury and ensure the patient's safety until the seizure subsides.

Correct Answer: D

Rationale: The correct concept that should be reinforced in the teaching plan is to systematically rotate injection sites. Rotating injection sites helps prevent lipodystrophy - changes in fat tissue due to repeated injections in the same spot. This can ensure that the insulin is properly absorbed and prevent complications. It is important for the child and their family to understand the importance of rotating injection sites to maintain good insulin absorption and reduce the risk of complications.

Correct Answer: B

Rationale: In a patient with Hirschsprung's disease presenting with fever and watery explosive diarrhea, these symptoms could indicate enterocolitis, which is a serious complication of the disease. Enterocolitis is characterized by inflammation of the intestines and can lead to significant complications if not promptly addressed. Therefore, the priority action for Nurse Joyce would be to immediately notify the physician so that appropriate interventions can be initiated promptly to manage the child's condition. Administering an antidiarrheal or monitoring the child would not be appropriate initial actions given the seriousness of the symptoms described.Ignoring these symptoms and doing nothing is also not advisable as prompt medical attention is necessary in this situation.

Correct Answer: D

Rationale: Tetralogy of Fallot is a congenital heart defect characterized by four primary abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Due to the pulmonary stenosis, less blood reaches the lungs to be oxygenated, resulting in deoxygenated blood entering the systemic arterial circulation. This leads to cyanosis, which is often referred to as "Tet spells" in these patients. Cyanosis is the bluish discoloration of the skin and mucous membranes caused by the presence of deoxygenated hemoglobin. The other conditions listed do not typically result in deoxygenated blood entering the systemic arterial circulation and causing cyanosis.

Correct Answer: C

Rationale: In status asthmaticus, a severe and prolonged asthma attack can lead to inadequate ventilation due to airway obstruction. This results in retention of carbon dioxide (CO2) in the blood, leading to respiratory acidosis. As the CO2 levels rise, it combines with water in the blood to form carbonic acid, lowering the blood pH levels. Symptoms of respiratory acidosis can include shortness of breath, confusion, lethargy, and potentially life-threatening complications. Treatment for status asthmaticus aims to improve ventilation and restore normal blood gas levels to alleviate respiratory acidosis.