A family brought their 3-week-old infant to the hospital by ambulance after having a seizure at home.
The baby received phenytoin in the ambulance and arrived at the hospital on 1 L/minute oxygen with a 22-gauge peripheral IV line in the left saphenous vein.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
Review H and P, nurse’s notes, flow sheet, and orders.
Call for a chest x-ray.
Hypocalcemia.
Monitor respiratory rate.
The Correct Answer is C
Choice A rationale
Reviewing the history and physical (H&P), nurse’s notes, flow sheet, and orders is a standard part of nursing care for any patient. However, in the case of a 3-week-old infant who has had a seizure, this action alone would not directly address the condition the infant is most likely experiencing.
Choice B rationale
While calling for a chest x-ray could be part of the diagnostic process for certain conditions, it is not typically the first action taken in response to a seizure in an infant.
Choice C rationale
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.
Choice D rationale
Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure. However, it does not specify the condition the infant is most likely experiencing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While a high-calorie, high-protein diet can be beneficial for patients recovering from surgery or illness, it is not the immediate next step after collecting bone aspirate specimens for culture and sensitivity and applying a cast to a patient’s lower leg. The priority is to address the infection identified through the bone aspirate specimens.
Choice B rationale
Beginning parenteral antibiotic therapy is the appropriate next step after collecting bone aspirate specimens for culture and sensitivity in a patient with osteomyelitis. Osteomyelitis is an infection in the bone, and antibiotics are typically the first line of treatment. Therefore, this choice is the correct answer.
Choice C rationale
Administering antiemetic agents would be appropriate if the patient were experiencing nausea or vomiting. However, there is no indication in the question that the patient is experiencing these symptoms. Therefore, this choice is not the correct answer.
Choice D rationale
Bivalving the cast for distal compromise would be appropriate if there were signs of compromised circulation or nerve function below the level of the cast. However, there is no indication in the question that the patient is experiencing these issues. Therefore, this choice is not the correct answer.
Correct Answer is A
Explanation
Choice A rationale
After a gastric endoscopy, it’s common for patients to experience a sore throat. This is due to the passage of the endoscope through the throat during the procedure. The discomfort is usually temporary and can be relieved with lozenges or gargling with warm salt water.
Choice B rationale
While headaches can occur after procedures that involve sedation, they are not commonly associated with gastric endoscopy specifically. Therefore, while it’s important to monitor for headaches, they are not a typical post-procedure problem following a gastric endoscopy.
Choice C rationale
Aching legs are not a common problem following a gastric endoscopy. The procedure primarily involves the upper gastrointestinal tract, and does not directly affect the legs.
Choice D rationale
Nausea can occur after a gastric endoscopy, but it is more commonly associated with the sedation used during the procedure rather than the procedure itself. If nausea does occur, it can be managed with antiemetic medications.
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