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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
Total daily dose: 1.5 mg
Divided into 3 equal doses: 1.5 mg / 3 = 0.5 mg per dose
Now, we can calculate the number of tablets:
Number of tablets = Desired dose (mg) / Tablet strength (mg/tablet)
Number of tablets = 0.5 mg / 0.5 mg/tablet = 1 tablet
Correct Answer is ["A","B","E"]
Explanation
A. They may believe that death is punishment for bad behavior. Preschool-aged children may have a limited understanding of death and may see it as a form of punishment for wrongdoing. They may not fully comprehend that death is a natural event.
B. They may believe that death is temporary or reversible. At this age, children tend to have magical thinking and may believe that the deceased person can come back to life or that they will return after a period of time.
E. They may believe that death is caused by their thoughts. Preschoolers often struggle with the concept of causality and may believe that their thoughts or wishes could cause something to happen, including death.
C. They may have a fear of death and view it as something to be avoided. While some preschoolers may fear death, this is more common in older children or adolescents who begin to grasp the permanency of death.
D. They understand death as a natural part of the life cycle. Preschool children typically do not have a fully developed understanding of death as part of the life cycle; they may not recognize its natural inevitability.
F. They have a concrete understanding of death as a permanent cessation of life. A concrete understanding of death is usually not achieved until later childhood (around 7-9 years of age) when children start to understand the permanence and finality of death.
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