A nurse in the provider's office is caring for a child who has a history of tonic-clonic seizure disorder. Three months ago, the neurologist changed the child's antiepileptic medications to include Phenytoin due to increasing number of seizures per guardian. The child has a 1-year history of mild exercise-induced asthma for which they were prescribed a rescue inhaler of albuterol prn.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Choice A reason: Gingival hyperplasia is a condition where the gums become enlarged and inflamed. It is a common side effect of Phenytoin, a medication used to treat seizures. The nurse should educate the client and the guardian about the importance of oral hygiene and regular dental check-ups to prevent or manage this condition.
Choice B reason: Hypoglycemia is a condition where the blood glucose level becomes too low. It is not a common side effect of albuterol, a medication used to treat asthma. Albuterol may cause tremors, tachycardia, or nervousness, but not hypoglycemia.
Choice C reason: Status epilepticus is a condition where seizures occur repeatedly without recovery. It is a medical emergency that requires immediate treatment. It may be triggered by exercise, but not necessarily. The nurse should ensure that the client has their seizure medication and rescue inhaler available at all times and knows how to use them.
Choice D reason: Bronchospasm is a condition where the airways become narrowed and obstructed. It is a common symptom of asthma, but not a side effect of Phenytoin. Phenytoin may cause other adverse effects, such as rash, nausea, or drowsiness, but not bronchospasm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: Holding the infant's chin to his chest and knees to his abdomen during the procedure is not a correct action for the nurse to take. This position may cause spinal cord compression or respiratory distress in the infant. The nurse should position the infant on his side with his back arched and his head and knees flexed.
Choice B reason: Placing the infant in an infant seat for 2 hr following the procedure is not a correct action for the nurse to take. This position may increase the intracranial pressure and cause headaches or vomiting in the infant. The nurse should keep the infant flat or slightly elevated for 4 to 6 hr after the procedure.
Choice C reason: Keeping the infant NPO for 6 hr prior to the procedure is not a correct action for the nurse to take. This may cause dehydration or hypoglycemia in the infant. The nurse should follow the provider's orders for fasting, which are usually 2 to 4 hr for clear liquids and 4 to 6 hr for solids.
Choice D reason: Applying a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure is a correct action for the nurse to take. This is a topical anesthetic that can reduce the pain and discomfort of the needle insertion. The nurse should apply the cream to the lower back and cover it with an occlusive dressing.
Correct Answer is C
Explanation
Choice A reason: This is not a correct instruction for the nurse to include in the teaching. Emphasizing the quantity, rather than the quality, of food consumed may lead to overeating, obesity, or malnutrition. The nurse should encourage the mother to offer a variety of healthy foods in appropriate portions and avoid forcing or bribing the child to eat.
Choice B reason: This is not a correct instruction for the nurse to include in the teaching. Expecting that food consumption might not decrease significantly may cause the mother to ignore the signs of poor nutrition or growth in the child. The nurse should advise the mother to monitor the child's weight, height, and development regularly and consult the provider if there are any concerns.
Choice C reason: This is a correct instruction for the nurse to include in the teaching. Adding fruit juice to the child's diet can increase the vitamin intake, especially vitamin C, which is important for immune function and wound healing. The nurse should recommend the mother to choose 100% fruit juice and limit the amount to 4 to 6 oz per day.
Choice D reason: This is not a correct instruction for the nurse to include in the teaching. Having the child remain at the table after meals to increase food intake may create a negative association with eating and cause more resistance or frustration. The nurse should suggest the mother to make mealtime a pleasant and relaxed experience and respect the child's appetite and preferences.
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