A nurse is admitting an 8-year-old child to the pediatric unit.
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The nurse should anticipate a provider's prescription for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for correct choices
• Preparing for a lumbar puncture: The child presents with fever, headache, nausea, irritability, lethargy, and nuchal rigidity, which are classic signs of meningitis or central nervous system infection. A lumbar puncture is the definitive diagnostic procedure to evaluate cerebrospinal fluid for infection, inflammation, or other abnormalities.
• Neurological findings: The neurological signs of lethargy, irritability, headache, and nuchal rigidity indicate possible central nervous system involvement. These findings guide the provider to order a lumbar puncture to confirm or rule out meningitis or other neurologic pathology. Early recognition and intervention are essential to prevent complications.
Rationale for incorrect choices
• Administering potassium chloride|: The child’s potassium level is 3.8 mEq/L, which is within normal limits (3.4–4.7 mEq/L). There is no indication for potassium supplementation at this time, making this intervention unnecessary.
• Administering acyclovir: Acyclovir is indicated for suspected viral infections such as herpes simplex encephalitis. While viral etiology may be considered later, the immediate priority is confirming meningitis through lumbar puncture rather than empiric antiviral therapy.
• Initiating airborne precautions: Airborne precautions are required for infections like measles, varicella, or tuberculosis. Meningitis is typically spread via droplet transmission, not airborne, so droplet precautions would be more appropriate if bacterial meningitis is suspected.
• Increasing environmental stimuli: The child exhibits irritability and lethargy; increasing stimuli could worsen agitation and interfere with assessment. The focus should be on providing a calm environment to safely evaluate neurological status.
• Lymph node findings: While lymphadenopathy may be relevant in some infections, the child’s current presentation of nuchal rigidity and neurologic symptoms takes priority for evaluation of CNS infection.
• Potassium level: Potassium is within normal limits, and there are no cardiac or metabolic indications for immediate intervention.
• Pain level: Although the child reports headache (pain 7/10), the neurological findings and risk for meningitis take precedence over pain management when anticipating a lumbar puncture.
• WBC: The WBC is elevated (14,000/mm³), which supports infection, but it alone does not dictate the need for a lumbar puncture. Neurological findings are the key indicator for this procedure.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer diuretics with the toddler's lunch: Giving diuretics with meals can increase urination, potentially disrupting rest and sleep. Timing medications to avoid frequent nighttime awakenings is important to help the toddler maintain adequate rest.
B. Establish a daily schedule with the toddler and their family: Creating a consistent daily routine helps the toddler anticipate activities and rest periods, reducing fatigue and promoting better sleep. Structured schedules are especially important for children with heart failure to balance activity and rest effectively.
C. Keep the television on in the toddler's room: Continuous television exposure can overstimulate the toddler and interfere with the ability to rest. A calm, quiet environment is more conducive to promoting restorative rest and reducing fatigue in children with heart failure.
D. Allow the toddler to visit the playroom 30 min prior to bedtime: Engaging in stimulating activities immediately before bedtime can make it harder for the toddler to fall asleep. Limiting high-energy play before rest periods supports better sleep and helps manage heart failure-related fatigue.
Correct Answer is C
Explanation
A. Follow up with physical therapy: Physical therapy is not a routine recommendation for newly diagnosed type 1 diabetes unless there are concurrent musculoskeletal or mobility issues. While exercise is important for blood glucose management, referral to a physical therapist is not required at diagnosis.
B. Store opened vials of insulin for up to 60 days: Most insulin vials are stable for 28–30 days once opened, depending on the type. Storing insulin beyond the recommended period can reduce potency and lead to poor glycemic control.
C. Consult with a nutritionist: Nutritional management is a cornerstone of type 1 diabetes care. A nutritionist can provide individualized meal planning, carbohydrate counting education, and guidance on balancing insulin dosing with food intake, which is critical for achieving glycemic control and preventing complications.
D. Monitor capillary blood glucose daily: Daily monitoring of blood glucose is essential, but in adolescents with type 1 diabetes, multiple checks per day are usually recommended to properly manage insulin dosing and respond to fluctuations. Advising consultation with a nutritionist addresses foundational management more comprehensively at diagnosis.
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