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 D

Explanation

A. "Get the child tested for Reye's syndrome if the child exhibits fever, vomiting, and lethargy.": While these are symptoms of Reye's syndrome, prevention focuses on avoiding triggers like salicylates during viral illnesses, not merely recognizing symptoms.

B. "Use aspirin instead of acetaminophen for children with viral illness.": Aspirin increases the risk of Reye's syndrome in children with viral illnesses.

C. "Advise parents to have their children immunized against Reye's syndrome.": There is no vaccine for Reye's syndrome; prevention relies on avoiding salicylate use during viral infections.

D. "Avoid giving salicylate-containing medications to a child who has a viral syndrome.": Salicylates, such as aspirin, are the primary risk factor for Reye's syndrome, so avoidance is critical.

A. Decreased pressure and cloudy cerebrospinal fluid with a high protein level. B. Clear cerebrospinal fluid with a high protein and low glucose. C. Cloudy cerebrospinal fluid with a low protein and low glucose. D. Cloudy cerebrospinal fluid with a high protein and low glucose levels.

Correct Answer is D

Explanation

A. Decreased pressure and cloudy cerebrospinal fluid with a high protein level. Meningitis usually causes increased intracranial pressure, not decreased.

B. Clear cerebrospinal fluid with a high protein and low glucose. Clear CSF is typically seen in viral meningitis, but bacterial meningitis more often causes cloudy CSF.

C. Cloudy cerebrospinal fluid with a low protein and low glucose. While glucose is low in bacterial meningitis, protein is typically elevated due to the infection.

D. Cloudy cerebrospinal fluid with a high protein and low glucose levels. This finding is consistent with bacterial meningitis, where the CSF is cloudy, protein is elevated due to inflammation, and glucose is low because bacteria consume glucose.

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Naxlex Comprehensive Predictor Exams

The nurse is planning to teach parents about prevention of Reye's syndrome. What information would the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is taking care of a child with a possible diagnosis of meningitis. The nurse knows to look for which laboratory results to verify the diagnosis?

Correct Answer is 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?

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

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?

Which diagnostic test is the most definitive test used to detect meningitis?

A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names?

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?

A nurse is reinforcing teaching with a 4-year-old child who is on airborne precautions about activities he can do while in the hospital. Which of the following activities should the nurse include in the teaching?

The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching?