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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 B

Explanation

A. Describing manifestations of the illness: Preschoolers lack the cognitive ability to describe symptoms in detail.

B. Relating fears to magical thinking: Magical thinking is characteristic of preschoolers, and they may associate illness with punishment or fantastical causes.

C. Awareness of body function: This is more typical of school-age children, not preschoolers.

D. Understanding cause of illness: Preschoolers do not have the cognitive development to understand illness causation fully.

Correct Answer is ["A","C","E"]

Explanation

A. Febrile episode: Fever is a common trigger for febrile seizures in children, especially between 6 months and 5 years.

B. Low blood lead levels: Elevated, not low, blood lead levels can increase the risk of seizures due to neurotoxicity.

C. Sodium imbalance: Both hyponatremia and hypernatremia can cause seizures by disrupting neuronal function.

D. Presence of diphtheria: Diphtheria does not directly increase the risk of seizures. Neurological complications are rare and secondary.

E. Hypoglycemia: Low blood sugar levels deprive the brain of energy, which can lead to seizures.

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