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 D
Explanation
Choice A rationale
Bluish-green discharge from the ear canal is not a typical finding in otitis media. This could suggest a different condition, such as an external ear infection or a ruptured eardrum.
Choice B rationale
Erythema and edema of the affected auricle (outer part of the ear) are not typical findings in otitis media. These symptoms are more commonly associated with conditions affecting the external ear, such as otitis externa.
Choice C rationale
An increase in appetite is not typically associated with otitis media. In fact, children with otitis media may have a decreased appetite due to discomfort or pain while swallowing.
Choice D rationale
Tugging on the affected ear lobe is a common sign of otitis media in infants and young children. This is often due to the pain and discomfort caused by the infection.
Correct Answer is ["1170 "]
Explanation
Step 1 is to convert all fluid intake to mL.
Using the conversion factor 1 oz = 30 mL7 and 1 cup
= 240 mL8, we get: 1 cup of coffee = 240 mL 4 oz of orange juice = 4 × 30 mL = 120 mL 3 oz of water = 3 × 30 mL = 90 mL 1 cup of flavored gelatin = 240 mL 1 cup of tea = 240 mL 5 oz of broth = 5 × 30 mL = 150 mL 3 oz of water = 3 × 30 mL = 90 mL Step 2 is to add up all the mL values: 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) + 240 mL (gelatin) + 240 mL(tea) + 150 mL (broth) + 90 mL (water) = 1170 mL So, the nurse should record a fluid intake of 1170 mL.
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