Page 1130 - Saunders Comprehensive Review For NCLEX-RN

Content Area: Pediatrics: Neurological
Health Problem: Pediatric-Specific: Hydrocephalus
Priority Concepts: Intracranial Regulation; Tissue Integrity
Reference: Hockenberry, Wilson, Rodgers (2017), pp. 906-908.

392. Answer: 1, 3, 5

Rationale: A seizure is a disorder that occurs as a result of excessive and
unorganized neuronal discharges in the brain that activate associated motor and
sensory organs. During a seizure, the child is placed on her or his side in a lateral
position. Positioning on the side prevents aspiration, because saliva drains out the
corner of the child’s mouth. The child is not restrained because this could cause
injury to the child. The nurse would loosen clothing around the child’s neck and
ensure a patent airway. Nothing is placed into the child’s mouth during a seizure,
because this action may cause injury to the child’s mouth, gums, or teeth. The nurse
would stay with the child to reduce the risk of injury and allow for observation and
timing of the seizure.
Test-Taking Strategy: Focus on the subject and visualize this clinical situation.
Recalling that airway patency and safety is the priority will assist in determining the
appropriate interventions.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Pediatrics: Neurological
Health Problem: Pediatric-Specific: Seizures
Priority Concepts: Intracranial Regulation; Safety
Reference: Hockenberry, Wilson, Rodgers (2017), p. 904.

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