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 C

Explanation

A. The nurse monitors the child's vital signs every 2 to 4 hours is appropriate. Regular monitoring of vital signs is important in children with neutropenia to detect early signs of infection or sepsis.

B. The nurse carefully washes his/her hands before and after providing care is appropriate. Hand hygiene is critical in preventing the transmission of infection, especially in neutropenic patients who are at high risk of infections.

C. The child has been placed in a semi-private room requires further education. A child with a neutrophil count of 225 is at significant risk of infection, and placing the child in a semi-private room increases the risk of exposure to pathogens. The child should be placed in a private room to minimize exposure to infectious agents.

D. The nurse assesses the child for clinical signs of an infection is appropriate. Vigilant monitoring for infection is essential in neutropenic patients, as they are more susceptible to infections.

A. An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin. B. An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin. C. An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin. D. An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin.

Correct Answer is C

Explanation

A. An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin is incorrect. An inguinal hernia involves a protrusion of bowel or fatty tissue through a weakness in the abdominal wall, not digestive fluids leaking from the bowel.

B. An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin is incorrect. Inguinal hernias are congenital or result from increased intra-abdominal pressure, not caused by viral infections.

C. An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin is correct. Inguinal hernias occur when tissue, usually part of the intestine or fatty tissue, pushes through a weak area in the abdominal wall near the groin. This condition is common in infants and children.

D. An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin is incorrect. While excess gas can cause bloating or discomfort, it is not responsible for the development of an inguinal hernia. The bulge is caused by the protrusion of tissue through a weakness in the abdominal wall.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A child has been admitted to the pediatric unit. Her absolute neutrophil count is 225 and the child has been placed in neutropenic isolation. Which action by a nurse indicates that the nurse requires further education? (Select all that apply)

Correct Answer is C

Explanation

A nurse is caring for a 4-year-old pediatric client who has an inguinal hernia. Which of the following statements should the nurse make when the parents ask for clarification about the inguinal hernia?

Correct Answer is C

Explanation

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.)

A nurse is caring for a child who has been diagnosed with a concussion. Which of the following findings should the nurse identify as causing this type of injury?

A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of the following warnings over the child's bed?

A school-age child with leukemia experienced severe nausea and vomiting when receiving chemotherapy for the first time. Which is the most appropriate nursing action to prevent or minimize these reactions with subsequent treatments?

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

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