A 15-month-old begins to seize during assessment for a high-grade fever. What is the most appropriate nursing action?

Question

Quizplus · Accepted Answer

This client likely has febrile seizures. It is important to never leave seizing clients alone as the goal is to prevent them from causing self-injury. The nurse should call out for help if needed. The main objective is to ensure that seizing clients maintain their airway; therefore, it is important to monitor their oxygen saturation levels. If these levels begin to drop or cyanosis occurs, prompt intervention is needed, which may be as simple as a head tilt or jaw thrust. (Option A) Aspirin should not be used in children to treat fever, except in a setting such as Kawasaki disease; this is because aspirin use is associated with Reye syndrome (swelling of the liver and brain). Fever in children is treated with ibuprofen or acetaminophen. (Option B) Most clients experiencing a febrile seizure do not require anti-seizure medications to stop convulsions. Once seizing has stopped, the fever needs to be treated. If seizing is continuous, medication administration may be necessary. (Option D) Many clients experiencing a febrile seizure are able to maintain their own airway with no intervention needed. It would not be necessary to bag mask this client if there are no signs of hypoxia or distress. Educational objective: Most clients experiencing a febrile seizure remain stable but still need continuous monitoring for hypoxia. They usually do not require anti-seizure medication. Ensuring client safety is important; therefore, the nurse should never leave a seizing client alone and stay to monitor oxygen saturation levels.

A 15-Month-Old Begins to Seize During Assessment for a High-Grade