A nurse is assisting with collecting data from a 10-month-old in the emergency department.
Medical History: Guardians brought the infant to the emergency room after witnessing the infant’s arms and legs shaking.
The infant did not respond to the guardians’ voices during that time.
The episode lasted approximately 5 min and the infant was sleeping soundly afterwards.
On the way to the emergency department, the infant had another episode of shaking of the extremities and drooling. The infant was asleep when they arrived for evaluation.
The infant has no prior medical or surgical history.
Born full-term at 40 weeks to a birth mother who had regular prenatal visits.
Actions to Take: 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.
Potential Condition
Parameters to Monitor 1
Parameters to Monitor 2
Vitamin
Blood pressure
The Correct Answer is A
The correct answer is A. Potential Condition.
The infant’s symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant’s neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Regular blood sugar testing is crucial for managing type 1 diabetes. It helps the child and their caregivers monitor the child’s blood sugar levels and make necessary adjustments to their insulin doses or diet.
Choice B rationale
This statement indicates a need for additional teaching. Even when sick, it’s important for individuals with type 1 diabetes to continue taking their insulin. Illness often causes blood sugar levels to rise, so insulin is still needed.
Choice C rationale
Rotating injection sites can help prevent skin problems, such as lipodystrophy (a lump under the skin caused by the accumulation of extra fat at the site of many subcutaneous injections of insulin). Therefore, this is a correct practice.
Choice D rationale
Physical activity can lower blood sugar levels. Eating a snack before physical activities like playing soccer can help prevent hypoglycemia (low blood sugar). This is a correct understanding of managing physical activity with type 1 diabetes.
Correct Answer is A
Explanation
The correct answer is A. Potential Condition.
The infant’s symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant’s neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.
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