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","E","F"]

Explanation

A. Aplastic crisis is caused by a decrease in the production of red blood cells in the bone marrow is correct. Aplastic crisis is often triggered by an infection (such as parvovirus B19), leading to a sudden reduction in red blood cell production, which can exacerbate anemia.

B. Sequestration crisis involves the blockage of small blood vessels by sickled red blood cells is incorrect. This describes a vaso-occlusive crisis, not sequestration crisis. Sequestration crisis involves pooling of blood in the spleen or liver, leading to organ enlargement and circulatory collapse.

C. Vaso-occlusive crisis is characterized by the pooling of large amounts of blood in the spleen and liver is incorrect. Vaso-occlusive crisis is characterized by the blockage of small blood vessels by sickled cells, leading to pain, ischemia, and tissue damage.

D. Aplastic crisis is characterized by the pooling of large amounts of blood in the spleen and liver is incorrect. Aplastic crisis is primarily related to bone marrow failure and reduced red blood cell production, not blood pooling in organs.

E. Sequestration crisis is characterized by the pooling of large amounts of blood in the spleen and liver is correct. In sequestration crisis, the spleen and liver trap large amounts of blood, which can lead to hypovolemic shock and severe anemia.

F. Vaso-occlusive crisis involves the blockage of small blood vessels by sickled red blood cells is correct. Vaso-occlusive crisis occurs when sickled red blood cells obstruct blood flow in small vessels, causing pain, tissue damage, and potential organ dysfunction.

A. "Palliative care serves to hasten death and make the process easier for the family." B. "Palliative care provides pain and symptom management and best quality of life for the child." C. "The goal of palliative care is to place the child in a hospice setting at the end of life." D. "The goal of palliative care is to act as the liaison between the family, child, and other health care professionals."

Correct Answer is B

Explanation

A. Palliative care serves to hasten death and make the process easier for the family is an incorrect statement. Palliative care is focused on providing relief from symptoms and improving the quality of life, not hastening death.

B. Palliative care provides pain and symptom management and best quality of life for the child is the correct understanding of palliative care. It focuses on managing symptoms and providing support to improve quality of life, regardless of the child’s age or stage of illness.

C. The goal of palliative care is to place the child in a hospice setting at the end of life is not entirely correct. Palliative care can be provided at any stage of a serious illness, not just at the end of life, and it does not automatically mean placement in hospice.

D. The goal of palliative care is to act as the liaison between the family, child, and other health care professionals is a supportive role, but it does not fully define the scope of palliative care, which is focused on symptom management and improving quality of life.

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Naxlex Comprehensive Predictor Exams

Which of the following accurately describe the differences between vaso-occlusive crisis, sequestration crisis, and aplastic crisis in sickle cell anemia? (Select All that Apply.)

Correct Answer is ["A","E","F"]

Explanation

The nurse and a new nurse (graduate nurse) are caring for a child who will require palliative care. Which statement made by the new nurse would indicate a correct understanding of palliative care?

Correct Answer is B

Explanation

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?

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

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

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 child who has been diagnosed with malignant neuroblastoma. Which of the following findings should the nurse expect?

A nurse is caring for a child who has increasing manifestations of fever, headache, stiff neck, and rash. Which of the following diagnostic tests should the nurse expect the health care provider to order?

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?