The home care nurse is assessing a 3 week old child with history of bilateral clubfoot noted at birth. The mother reports that the infant has been increasingly irritable in the last day. Assessment findings include: bilateral leg casts in place, child is irritable; pallor and coolness of left foot is noted. What is the nurse's priority action?

Provide range of motion exercises for both lower extremities

Assess for skin breakdown

Refer child for immediate intervention in Emergency Department

Provide cast care for the infant

Answer and Explanation

The Correct Answer is C

A. Range of motion exercises are not appropriate with casts in place and do not address the urgent symptoms.

B. Assessing for skin breakdown is important but does not address the immediate priority.

C. Pallor and coolness indicate compromised circulation, which requires immediate intervention to prevent tissue damage.

D. Cast care is essential but does not address the urgent vascular concern.

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A. Physical activity can help manage blood sugar and improve overall health.

B. Blood sugar monitoring is essential for managing diabetes.

C. Skipping meals can cause blood sugar fluctuations and should be avoided.

D. A balanced diet helps maintain healthy blood sugar levels.

E. Limiting to 1000 calories/day is generally not appropriate for children as it may lead to malnutrition.

A. Fever and photophobia B. Increased heart rate and respiratory rate C. Headache and vomiting D. Bulging anterior fontanelle

Correct Answer is C

Explanation

A. Fever and photophobia are common symptoms of meningitis but do not indicate increased ICP.

B. Increased heart and respiratory rates are not specific signs of increased ICP.

C. Headache and vomiting are classic signs of increased ICP in children with meningitis.

D. A bulging anterior fontanelle may indicate increased ICP in infants, but this is not applicable to a 5-year-old.

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Naxlex Comprehensive Predictor Exams

Which of the following topics should be included in patient teaching for a child with type 2 diabetes? SATA

Correct Answer is ["A","B","D"]

Explanation

The nurse is caring for a 5 year old child with meningitis. Which of the following signs or symptoms may indicate increased intracranial pressure in this child?

Correct Answer is C

Explanation

The nurse provides education to the parent of an infant being treated for hydrocephalus with a ventriculoperitoneal (VP) shunt. Which statement by the parent indicates the need for further instruction?

A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care?

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

When planning the discharge of a child with juvenile idiopathic arthritis, which intervention should the nurse include in the plan of care to promote joint mobility and reduce pain?

A nurse in a special education program is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

A nurse is discharging a 12 year old client who came to the outpatient clinic with an ankle sprain with their parent. Which of the following statements should the nurse identify as an indication that the client and parent understand the discharge instructions?

What are some risks associated with the treatment of Rh Isoimmunization as in hemolytic disease of the newborn (HDN). Choose all that applies: (Select All that Apply.)

A parent brings a 12-month-old child diagnosed with congenital cerebral palsy to the clinic. The nurse completes an assessment. Which assessment finding does the nurse determine needs immediate intervention?