Page 1123 - Saunders Comprehensive Review For NCLEX-RN

▪ Have suction equipment and oxygen available.

▪ Time the seizure episode.
▪ If the child is standing or sitting, ease the child down to the floor and place the
child in a side-lying position.

▪ Place a pillow or folded blanket under the child’s head; if no bedding is
available, place your own hands under the child’s head or place the child’s head
in your own lap.
▪ Loosen restrictive clothing.
▪ Remove eyeglasses from the child if present.
▪ Clear the area of any hazards or hard objects.

▪ Allow the seizure to proceed and end without interference.
▪ If vomiting occurs, turn the child to one side as a unit.
▪ Do not restrain the child, place anything in the child’s mouth, or give any food
or liquids to the child.
▪ Prepare to administer medications as prescribed.
▪ Remain with the child until the child recovers fully.
▪ Observe for incontinence, which may have occurred during the seizure.
▪ Document the occurrence.

Practice Questions

382. The parents of a child recently diagnosed with cerebral palsy ask the nurse
about the limitations of the disorder. The nurse responds by explaining that
the limitations occur as a result of which pathophysiological process?
1. An infectious disease of the central nervous system
2. An inflammation of the brain as a result of a viral illness
3. A chronic disability characterized by impaired muscle movement
and posture
4. A congenital condition that results in moderate to severe
intellectual disabilities
383. The nurse notes documentation that a child is exhibiting an inability to flex
the leg when the thigh is flexed anteriorly at the hip. Which condition does
the nurse suspect?
1. Meningitis
2. Spinal cord injury
3. Intracranial bleeding
4. Decreased cerebral blood flow
384. A mother arrives at the emergency department with her 5-year-old child and
states that the child fell off a bunk bed. A head injury is suspected. The nurse
checks the child’s airway status and assesses the child for early and late signs
of increased intracranial pressure (ICP). Which is a late sign of increased
ICP?
1. Nausea
2. Irritability
3. Headache

1123