A nurse is assisting with collecting data from a 10-month-old in the emergency department.

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 []

Condition the Client Is Most Likely Experiencing:

Tonic-Clonic Seizures: The infant exhibited rhythmic shaking of arms and legs, unresponsiveness during the episode, and postictal sleep, all characteristic of tonic-clonic seizures. These seizures often involve loss of consciousness and rhythmic convulsions of extremities.

Actions to Take:

Initiate Seizure Precautions: Safety is paramount during and after a seizure to prevent injury. Seizure precautions may include padding the bed rails, ensuring airway patency, and having suction equipment available.
Keep infant NPO until they are fully awake and alert: Keeping the infant NPO (nothing by mouth) until they are fully awake and alert is crucial to prevent aspiration, which can occur if the infant is fed while still drowsy or lethargic after a seizure.

Parameters to Monitor:

Level of Consciousness (LOC): Monitoring LOC helps assess the child’s neurological recovery post-seizure and detect worsening neurological status. Persistent lethargy or confusion could indicate prolonged postictal states or complications.
Motor Ability: Monitoring motor ability is essential to assess for postictal paresis (e.g., Todd's paralysis) or other neurological deficits resulting from the seizure.

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Correct Answer is B

Explanation

A. Detachment is the stage exhibited only in the hospital: Detachment can occur in other settings beyond the hospital. It is the final stage of separation anxiety and may manifest as a child appearing uninterested in caregivers, a coping mechanism to deal with prolonged separation.

B. Physical aggression such as kicking is an example of separation anxiety: Physical aggression, such as kicking or hitting, is a common behavior during separation anxiety, especially in younger children who cannot verbalize their emotions effectively.

C. It results in prolonged issues of adaptability: While separation anxiety may temporarily affect adaptability, most children overcome it as they grow. It does not inherently result in prolonged issues unless associated with other psychological conditions.

D. It is often observed in the school-aged child: Separation anxiety is most commonly observed in infants and toddlers (6 months to 3 years). By school age, children have typically developed coping mechanisms, though they may experience situational anxiety.

A. Dropping held object B. Loss of consciousness C. Falling to the floor D. Appearance of daydreaming

Correct Answer is ["A","B","D"]

Explanation

A. Dropping held object: Loss of motor activity during absence seizures may result in dropping objects.

B. Loss of consciousness: Absence seizures involve brief, sudden loss of consciousness without convulsions.

C. Falling to the floor: This is associated with atonic or tonic-clonic seizures, not absence seizures.

D. Appearance of daydreaming: A hallmark of absence seizures is the "staring spell" or daydream-like appearance.

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a group of caregivers about separation anxiety in the pediatric setting. Which of the following information should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response?

Which of the following is a common treatment for seizures?

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

A nurse is attending a continuing education course about communicable diseases. The nurse should identify that varicella has which of the following incubation periods?

Which of the following is a common symptom of meningitis?

A nurse enters a school age child's room to administer morning medications and finds the client sitting in a chair having a seizure. After lowering the client to the floor, which of the following actions should the nurse take first?

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