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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

A. Nausea is a common side effect of both chemotherapy and radiation therapy. Antiemetics are often used to manage this adverse effect.

B. Hair loss is a well-known side effect of chemotherapy, as it affects rapidly dividing cells, including those in hair follicles. Radiation therapy to the head or neck area can also cause localized hair loss.

C. Diarrhea is a potential side effect of chemotherapy and radiation, particularly when the digestive tract is affected. Some chemotherapies and radiation treatments irritate the gastrointestinal system, leading to diarrhea.

D. Skin Sensitivity can result from radiation therapy, especially in the treated area. The skin may become red, irritated, and sensitive.

E. Weight gain is not typically associated with chemotherapy or radiation therapy. In fact, many children experience weight loss due to nausea, decreased appetite, or other side effects.

A. Increased temperature, tachycardia, tachypnea B. Decreased temperature, bradycardia, bradypnea C. Bradycardia, high blood pressure, irregular respirations D. Bradycardia, hypotension, tachypnea

Correct Answer is C

Explanation

A. Increased temperature, tachycardia, tachypnea is not consistent with Cushing's triad. These signs generally reflect an infection, fever, or a stress response, and are not indicative of increased intracranial pressure (ICP) or brain herniation.

B. Decreased temperature, bradycardia, bradypnea is incorrect. While bradycardia is a component of Cushing's triad, decreased temperature and bradypnea are not part of this syndrome. The signs of Cushing's triad typically include increased blood pressure, not decreased temperature.

C. Bradycardia, high blood pressure, irregular respirations is correct. These are the hallmark signs of Cushing's triad, which indicate a significant increase in intracranial pressure. Bradycardia occurs as a result of elevated pressure on the brainstem, high blood pressure develops as a compensatory mechanism to maintain perfusion, and irregular respirations reflect brainstem dysfunction.

D. Bradycardia, hypotension, tachypnea is incorrect. Hypotension is not part of Cushing's triad. Instead, high blood pressure is typically present in this condition due to the body's compensatory response to increased ICP.

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Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a pediatric client who has been diagnosed with osteosarcoma and will be receiving chemotherapy with radiation interventions. The nurse should monitor the client for which of the following expected adverse effects? (Select All that Apply.)

Correct Answer is ["A","B","C","D"]

Explanation

The nurse is monitoring a 7-year-old child post-surgical resection of a supratentorial (cerebral) brain tumor. Which vital sign finding indicates Cushing's triad?

Correct Answer is C

Explanation

A nurse is screening a child for epilepsy. Which of the following questions should the nurse ask the client's parent?

At what age is it generally recommended to perform palatoplasty for a child with a cleft palate?

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 in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

A nurse is caring for a client who presents to the emergency room in sickle cell crisis. Which of the following medications should the nurse anticipate administering?

A nurse is assessing a child with iron deficiency anemia. Which of the following is NOT an expected finding?

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?

Which of the following is a risk factor for iron deficiency anemia in toddlers?