Practice Question
A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)
Answer Choices:
Correct Answer:
Clear the area of hard objects.
Rationale:
Clear the area of hard objects.
🔷Clearing nearby hard or sharp objects is an immediate injury-prevention measure during a seizure, when uncontrolled tonic-clonic movements raise the risk of head strikes, lacerations, and fractures.
🔷Creating a safe perimeter (moving furniture, equipment, IV poles) prevents secondary trauma without touching or restraining the child.
🔷This step preserves the nurse’s ability to observe breathing pattern, color, and seizure characteristics while maintaining environmental control.
🔷It aligns with evidence-based seizure first aid: protect from injury, do not restrain, and do not place objects in the mouth.
🔷Rapid environmental control is high-yield and low-risk, buying time for follow-up priorities (e.g., side-lying positioning, timing, and postictal assessment).
🔷In bed, raise and pad side rails when available to limit impact without restricting movement or compromising access to the airway.
Loosen restrictive clothing.
🔷Loosening tight clothing—especially around the neck and chest—optimizes airflow, chest expansion, and venous return, reducing the risk of hypoxia during convulsive phases.
🔷Neck garments (ties, tight collars, scarves) can increase upper-airway resistance; easing them supports spontaneous ventilation while you position the child side-lying for secretion drainage.
🔷This intervention complements airway protection without inserting anything in the mouth or applying restraints, both of which can cause injury or obstruction.
🔷Maintaining circulatory and respiratory ease also facilitates accurate assessment of work of breathing, skin color, and oxygenation.
🔷It is a rapid, noninvasive step that preserves dignity and temperature control while prioritizing A-B-C until the seizure resolves.
🔷Together with environmental safety, this supports the overarching goals of preventing aspiration, minimizing trauma, and ensuring adequate ventilation.
Want to practice more questions like this?
This question is from VN 410 PEDS QUIZ-5 SENSORINEURO which contains 50 questions.
More Questions from This Exam
A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media?
Answer Choices:
What does the nurse explains to parents of a child with febrile seizures?
Answer Choices:
An adolescent has just had a generalized seizure and collapsed in the school nurses office. When should the nurse should call 9112
Answer Choices:
Often referred to as swimmer's ear:
Answer Choices:
A child who had a seizure one hour ago is exhibiting signs of temporary paralysis, confusion and aggressive behavior. The nurse understands the child is exhibiting signs of:
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Pediatrics
- Answer Choices: 5