A nurse in the emergency department is assessing a 10-month-old infant.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Absence Seizures:

The infant’s clinical presentation, including shaking of the arms and legs, lack of response to touch or voice, and the brief episodes of unconsciousness (lasting around 5 minutes), is consistent with absence seizures (also known as petit mal seizures). These seizures typically involve brief episodes of altered consciousness with subtle motor activity like shaking or jerking, and the child resumes normal activity afterward. The child’s seizure episodes seem to stop on their own, and the child appears to sleep soundly after the episodes, which further points to absence seizures.

Actions to Take:

Initiate seizure precautions:

Seizure precautions are essential to ensure the infant’s safety during and after a seizure episode. This includes making sure the environment is free from hazards and that the infant is being closely monitored.

Keep infant NPO until they are fully awake and alert:

Keeping the infant NPO (nothing by mouth) is essential to prevent aspiration risk during and after the seizure. Once the infant is fully awake and alert, they can resume normal feeding.

Parameters to Monitor:

Level of consciousness:

Monitoring the infant’s level of consciousness is crucial because the primary concern during absence seizures is the alteration of consciousness. After the seizure, assessing their responsiveness and mental state will help evaluate the resolution of the episode.

Motor ability:

The motor ability should be monitored to check for any residual effects from the seizure, such as weakness or abnormal movements, and to assess for any motor symptoms during the seizure.

Explanation of Incorrect Choices:

Akinetic seizures:

Akinetic seizures involve loss of muscle tone and are often associated with sudden collapse or "drop attacks." This is not consistent with the infant’s symptoms, which include shaking rather than sudden loss of muscle tone.

Tonic-clonic seizures:

Tonic-clonic seizures (grand mal seizures) typically involve both tonic (muscle stiffening) and clonic (jerking) movements with a loss of consciousness. While the infant is having shaking episodes, the description does not indicate the full tonic-clonic presentation.

Focal seizures with impaired awareness:

Focal seizures typically involve abnormal activity in one part of the brain and often manifest with

symptoms localized to one area of the body. This infant’s symptoms are more generalized, with shaking

in the arms and legs, and a lack of response, which aligns better with absence seizures.

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Free Nursing Study Resources

Correct Answer is ["B","C","E"]

Explanation

A. NSAIDs may help with pain management, but they are not the primary treatment for SCFE.
B. Restricting weight-bearing activities is crucial to prevent further damage and complications to the affected hip joint.
C. Crutches may be prescribed to assist with mobility and prevent weight-bearing on the affected hip.
D. Ice packs may reduce inflammation but are secondary to more important interventions like weight restriction and orthopedic referral.
E. Immediate referral to an orthopedic specialist is necessary for appropriate diagnosis and management, including possible surgery.
F. Heat packs are not recommended for SCFE because they could increase blood flow and swelling in the affected area.

A. Edema with normal or low BP B. Edema with hypertension C. Unexpected weight loss D. Frequency and urgency

Correct Answer is A

Explanation

A. Edema with normal or low BP is correct. In nephrotic syndrome, fluid retention leads to edema, and blood pressure is typically normal or low due to the loss of protein in the urine and reduced plasma oncotic pressure.
B. Edema with hypertension is less common in nephrotic syndrome but may occur in cases with significant fluid retention or other complications.
C. Unexpected weight loss is incorrect. Weight gain due to fluid retention is a hallmark of nephrotic syndrome.
D. Frequency and urgency are not common symptoms of nephrotic syndrome; these are more typical of urinary tract infections.

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