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: C

Rationale: According to the Centers for Disease Control and Prevention (CDC), motor vehicle–related fatalities are the leading cause of death from unintentional injuries for females aged 1 to 14. This is a significant risk factor for young girls in this age group, highlighting the importance of road safety measures and injury prevention strategies. Factors such as proper car seat usage, seat belt use, and safe driving practices are crucial in reducing the number of motor vehicle-related fatalities among young females aged 1 to 14.

Correct Answer: D

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to impaired clot formation and increased risk of bleeding. With a low platelet count, there is an increased risk of internal bleeding and hemorrhage, which can affect vital organs such as the brain, heart, and gastrointestinal tract. Therefore, the priority nursing diagnosis for a client with thrombocytopenia receiving chemotherapy would be Ineffective tissue perfusion: Cerebral, cardiopulmonary, GI. Monitoring for signs of internal bleeding, such as changes in mental status, chest pain, and abdominal pain, is crucial to prevent potential life-threatening complications.

Correct Answer: C

Rationale: An important nursing consideration when caring for a child with herpetic gingivostomatitis (HGS) is to wait to brush teeth until lesions are sufficiently healed. This is because brushing teeth while the lesions are present can be painful and potentially disruptive to the healing process. It is important to ensure that the child is comfortable and that the healing of the lesions is not impeded by brushing too early. This consideration helps promote optimal healing and comfort for the child with this condition.

Correct Answer: C

Rationale: Infants with congenital heart disease who have been admitted with heart failure may have difficulty feeding due to increased work of breathing and poor energy reserves. Offering small, frequent feedings can help prevent fatigue and provide adequate nutrition to support the infant's growth and recovery. It also helps to prevent overloading the heart with a large volume of fluids at once. This approach allows the infant to receive enough calories while reducing the risk of aspiration and conserving energy for feeding and breathing. Positioning the infant flat on the back may worsen respiratory distress, encouraging nutritional fluids alone may not address the feeding challenges faced by the infant, and measuring the head circumference is important for growth monitoring but may not be the priority when managing heart failure in this case.