A 12-year-old child is being admitted to the pediatric unit. What is the priority nursing action based on these the data below? Vital signs: T: 104F (40C) P: 89, R: 30, B/P: 80/42 Nurse's notes: Difficult to arouse, c/o headache, emesis x2, exhibiting nuchal rigidity, slight petechiae noted on distal extremities, lumbar puncture completed with results of elevated WBCs in CSF, decreased glucose in CSF.

Administer antipyretic therapy

Place the child in a lateral Sims position

Place the child on droplet precautions

Reduce all environmental stimuli

Answer and Explanation

The Correct Answer is C

A. Administer antipyretic therapy is appropriate to help reduce fever, but it is not the first priority. The child’s vital signs indicate a high fever and signs of possible meningitis, and intervention to prevent further complications or the spread of infection should take precedence.

B. Place the child in a lateral Sims position is unnecessary in this case. A lateral Sims position is typically used to prevent aspiration during vomiting, but it is not the priority for this child. The focus should be on infection control and stabilizing the child’s condition.

C. Place the child on droplet precautions is the correct priority. The child is showing signs of possible bacterial meningitis, which is a highly contagious infection. Droplet precautions are necessary to prevent transmission of the infection to other individuals.

D. Reduce all environmental stimuli may be helpful for a child with a neurological condition, but it is not the first priority in this case. The priority is preventing the spread of infection while further stabilizing the child’s condition.

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Correct Answer is D

Explanation

A. While alterations in pupil size and reactivity are signs of increased ICP, increased motor response is not a late sign and typically reflects an early sign of brain dysfunction.

B. Extension or flexion posturing may occur with increased ICP, but weight gain is not a sign of ICP.

C. Tachycardia can occur early in ICP, but it does not typically present as a late sign. Altered pupil size and reactivity may occur, but these are not exclusive to late ICP signs.

D. This is the correct answer. Cheyne-Stokes respirations, which are characterized by alternating periods of apnea and deep breathing, are a late sign of increased ICP in infants. Additionally, changes in pupil size (such as dilated or non-reactive pupils) are a late indicator of increasing intracranial pressure.

A. Place the client in a semi-Fowler's position. B. Admit the client to a private room. C. Implement seizure precautions. D. Measure head circumference every shift.

Correct Answer is D

Explanation

A. Placing the client in a semi-Fowler's position is appropriate to help alleviate pressure on the brain and improve comfort. This position can also help with respiratory function, which may be compromised in meningitis.

B. Admitting the client to a private room is necessary to prevent the spread of the infection to other patients. Bacterial meningitis is highly contagious, and isolation is important to limit exposure.

C. Implementing seizure precautions is essential in managing a child with bacterial meningitis because the infection can cause increased intracranial pressure, which may lead to seizures.

D. Measuring head circumference every shift is unnecessary for this child, as it is typically done for infants to monitor for signs of hydrocephalus or increased intracranial pressure. In a 6-year-old child, clinical signs and imaging studies are more reliable for monitoring ICP.

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Naxlex Comprehensive Predictor Exams

The nurse is monitoring an infant for signs of increased intracranial pressure (ICP). Which are late signs of increased intracranial pressure (ICP) in an infant?

Correct Answer is D

Explanation

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Correct Answer is D

Explanation

Which assessment finding would the nurse expect in an infant with Hirschsprung's disease?

A nurse is assessing a pediatric client who is exhibiting manifestations of rhabdomyosarcoma. In which area of the body should the nurse expect to find a tumor?

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care?

A nurse manager is preparing to discuss methods to help staff who care for terminally ill children cope with the stress of caring for their patients and families. Which of the following information should the nurse plan to include in the discussion? (Select All that Apply.)

During an episode of status epilepticus of a hospitalized child, what is the priority intervention?

Which of the following is a complication of hemophilia?

A nurse is educating a family about bleeding disorders while they await the results of their child's laboratory testing. Which of the following statements accurately describes the differences in the causes of hemophilia A, hemophilia B, and von Willebrand disease? (Select All that Apply.)