A nurse in the provider's office is assisting with the care of a child.

Exhibits

Upon review of the child's electronic medical record (EMR), the nurse should determine the child is at risk for developing which of the following conditions? Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
dropdown
due to
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Increased seizure activity

Finding: Phenytoin level

The child's phenytoin level is 6 mcg/mL, which is below the therapeutic range of 10-20 mcg/mL. Subtherapeutic levels of phenytoin mean the medication is not providing adequate seizure control, increasing the risk of more seizures. The recent seizure history and the low drug level indicate a direct correlation between insufficient phenytoin levels and increased seizure activity.

Pneumonia

Finding: Cough

A harsh, non-productive cough that worsens with activity and at night can be indicative of respiratory conditions, including asthma exacerbations. However, in the context of this child's history and symptoms, there is no evidence of a productive cough, fever, or other signs of infection that would typically suggest pneumonia. Hence, pneumonia is not the primary concern.

Liver failure

Finding: Skin rash

Liver failure is usually associated with jaundice, elevated liver enzymes, and systemic symptoms like fatigue or confusion. The child’s liver function tests are within normal ranges, and there are no signs of jaundice or systemic illness. The skin rash is more likely related to eczema or a possible drug reaction rather than indicating liver failure.

Steven-Johnson syndrome

Finding: Liver enzymes

Steven-Johnson syndrome (SJS) is a severe skin reaction typically triggered by medications, including anticonvulsants. Elevated liver enzymes can be seen in SJS, but the child’s liver enzymes are within normal ranges. The rash described does not match the characteristics of SJS, which typically presents with widespread, painful, blistering rashes, not localized eczema patches. Therefore, SJS is unlikely in this scenario.

Pneumothorax

Finding: Lung sounds

A pneumothorax would usually present with decreased breath sounds, possibly on one side, along with signs of respiratory distress such as tachypnea and cyanosis. The child has slight end expiratory wheezes but normal respiratory rates and oxygen saturation, which suggests asthma rather than pneumothorax. Therefore, pneumothorax is not a primary concern here.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "My baby's fingers are looking swollen.": Swelling around the IV site can indicate infiltration, where IV fluids leak into surrounding tissues rather than being infused into the vein.

B. "The tape is coming off the IV needle.": While loose tape may need to be replaced, it does not specifically indicate infiltration.

C. "There's blood backing up my baby's IV tubing.": Blood backflow can indicate various issues such as improper placement or the IV being too low, but not necessarily infiltration.

D. "There's a long red streak up my baby's arm.": A red streak can indicate phlebitis, inflammation of the vein, rather than infiltration, which typically presents with swelling and coolness around the IV site.

A. Modeling clay B. Brightly-colored mobile C. 100-piece jigsaw puzzle D. Checkerboard and checkers

Correct Answer is A

Explanation

A. Modeling clay: Correct. This is appropriate for a 4-year-old, helping with fine motor skills and creativity.

B. Brightly-colored mobile: Incorrect. More suitable for infants who are visually stimulated by simple, moving objects.

C. 100-piece jigsaw puzzle: Incorrect. Too complex for a 4-year-old; age-appropriate puzzles typically have fewer pieces.

D. Checkerboard and checkers: Incorrect. This is better suited for older children who understand rules and strategies.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?

Correct Answer is A

Explanation

A nurse is planning care for a 4-year-old child who has been admitted to the hospital. Which of the following toys should the nurse plan to provide the child?

Correct Answer is A

Explanation

A nurse is reinforcing discharge instructions with a parent of a 6-year-old child who has just had a tonsillectomy. Which of the following statements by the parent indicates an understanding of postoperative care?

A nurse is assisting in the care of an infant who has congenital heart disease. Exhibits

A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first?

A nurse is caring for a 4-year-old child who is postoperative following abdominal surgery. Which of the following statements should the nurse make to encourage the child to take deep breaths?

A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

A nurse is caring for a 2-week old Infant whose mother requests additional information about sudden infant death syndrome (SIDS). Which of the following responses should the nurse make?

A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?

A nurse is reviewing the medical record of a toddler who has moderate dehydration. Which of the following findings should the nurse expect?