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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:

  1. 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.
  2. 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:

  1. 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.
  2. 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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Related Questions

Correct Answer is A

Explanation

A. 2 to 3 weeks: The incubation period for varicella is typically 10 to 21 days, or 2 to 3 weeks.

B. 7 to 10 days: This is shorter than the actual incubation period for varicella.

C. 3 to 4 weeks: This exceeds the typical maximum incubation period of 21 days.

D. 2 to 5 days: This is significantly shorter than the typical incubation period for varicella.

Correct Answer is C

Explanation

A. "I know that my child will need to have a companion when swimming." This is a correct precaution to prevent drowning in case of a seizure.

B. "I will make my child wear a medical identification bracelet." This is correct to alert others in case of an emergency.

C. "I will need to give antiseizure medications when my child has a seizure." Antiseizure medications are typically administered as a preventive measure, not during a seizure. Emergency medications (e.g., rectal diazepam) may be used for prolonged seizures but are not routine for every seizure.

D. "I will have my child wear a bike helmet when riding a bike or skateboard." This is correct to protect the child from head injuries during activities.

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