A 9-month-old with Tay-Sachs disease is admitted due to seizures. Which assessment is most important for the nurse to obtain?
Ability to crawl.
Eyes with cherry-red spot.
Difficulty with swallowing.
Exaggerated startle reaction
The Correct Answer is D
Choice A reason: The ability to crawl is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes progressive loss of motor skills, so the infant may not be able to crawl or may have regressed from crawling. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice B reason: The eyes with cherry-red spot are not the most important assessment for the nurse to obtain. Tay-Sachs disease causes accumulation of gangliosides in the retina, which results in a cherry-red spot in the center of the macula. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice C reason: The difficulty with swallowing is not the most important assessment for the nurse to obtain. Tay-Sachs disease causes muscle weakness and spasticity, which may affect the infant's ability to swallow. However, this is not a specific sign of the disease and does not indicate the severity of the condition.
Choice D reason: The exaggerated startle reaction is the most important assessment for the nurse to obtain. Tay-Sachs disease causes increased sensitivity to sound and touch, which results in an exaggerated startle reaction. This is a specific sign of the disease and indicates the severity of the condition. The exaggerated startle reaction may also trigger seizures, which can be life-threatening. The nurse should monitor the infant's vital signs, seizure activity, and neurological status closely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Applying a cool pack to the injection site is a simple and effective way to reduce discomfort after receiving the varicella vaccine. The cool pack can help numb the pain, decrease swelling, and prevent bruising. The nurse should instruct the parent to apply the cool pack for 10 to 15 minutes at a time, several times a day, as needed.
Choice B reason: Any level of fever is not serious and does not need to be reported right away. Fever is a common side effect of the varicella vaccine and usually lasts for 1 to 2 days. Fever is a sign that the body is developing immunity against the chickenpox virus. The nurse should instruct the parent to monitor the child's temperature and give them acetaminophen or ibuprofen to lower the fever, if necessary. The nurse should also advise the parent to call the health care provider if the fever is higher than 102°F (38.9°C) or lasts longer than 3 days.
Choice C reason: Chewable children's aspirin will not help prevent inflammation and may cause serious harm. Aspirin is not recommended for children under 18 years of age who have viral infections, such as chickenpox, because it can increase the risk of Reye's syndrome, a rare but potentially fatal condition that affects the brain and liver. The nurse should instruct the parent to avoid giving the child aspirin or any products that contain aspirin, such as bismuth subsalicylate.
Choice D reason: Keeping the child home from daycare for the next two days is not necessary and may be inconvenient. The varicella vaccine is very effective at preventing chickenpox and does not pose a risk of spreading the virus to others. The nurse should instruct the parent to resume the child's normal activities, unless they have other symptoms that warrant staying home, such as rash, vomiting, or diarrhea.
Correct Answer is C
Explanation
Choice A reason: Giving prescribed intravenous antibiotics is not the first action that the nurse should take. Antibiotics are used to treat the infection and inflammation caused by appendicitis, but they are not enough to prevent the complications of a ruptured appendix. The nurse should administer the antibiotics as ordered, but only after notifying the healthcare provider of the change in the child's condition.
Choice B reason: Inquiring about the client's last meal is not the first action that the nurse should take. The last meal may be relevant for the preparation of the surgery, but it is not urgent or related to the sudden relief of pain. The nurse should ask about the last meal as part of the preoperative assessment, but only after contacting the healthcare provider.
Choice C reason: Contacting the healthcare provider is the first action that the nurse should take. Sudden relief of pain in a child with appendicitis may indicate a perforation or rupture of the appendix, which is a life-threatening emergency. The nurse should immediately report this finding to the healthcare provider, who may order additional tests or expedite the surgery.
Choice D reason: Documenting the client's relief of pain is not the first action that the nurse should take. Documentation is an important part of nursing care, but it is not a priority in this situation. The nurse should document the child's pain level, vital signs, and interventions, but only after contacting the healthcare provider and taking appropriate actions.
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