A 2-year-old starts to have a tonic-clonic (grand mal) seizure ...

[javeds]

A 2-year-old starts to have a tonic-clonic (grand mal) seizure while in a crib in the hospital. The child's jaws are clamped. The most important nursing action at this time is which of the following?
 
  1. Place a padded tongue blade between the child's jaws
   2. Stay with the child and observe the respiratory status
   3. Prepare the suction equipment
   4. Restrain the child to prevent injury

Question 2

The client has presented with complaints of mouth soreness. A review of the client's medical health history reveals gastric bypass surgery one year ago. During the assessment, the nurse notes the client's tongue is beefy, red, and smooth.
 
  Based upon your knowledge, what do you anticipate will be included in the diagnostic workup ordered for the client? 1. Vitamin B12 levels
   2. Iron levels
   3. Vitamin B6 levels
   4. Potassium levels

[juliaf]

Answer to Question 1

2. Stay with the child and observe the respiratory status

Rationale:
During a seizure the nurse remains with the child, watching for complications. The child's respiratory rate should be monitored. Be sure nothing is placed in the child's mouth during a seizure. Suction equipment should already be set up at the bedside before a seizure begins. The child should not be restrained during a seizure.

Answer to Question 2

1. Vitamin B12 levels

Rationale:
Vitamin B12 deficiency is associated with gastric bypass surgery. A deficiency of vitamin B12 levels will result in pernicious anemia. This deficiency will manifest as pallor, jaundice, and weakness, and a beefy, smooth red tongue. Iron-deficiency anemia will manifest with weakness and fatigue. Vitamin B6 deficiencies are not typically seen with gastric bypass surgeries and are not manifested with a beefy, red, smooth tongue. The client's reports are not consistent with a potassium deficiency.