The nurse has reviewed the Nurses' Notes, the Vital Signs at 1000 and 1030, and the Laboratory Results at 1030.
Complete the following sentence by using the lists of options.
The nurse should first address the adolescent's
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale for correct choices:
• Blood pressure: The adolescent’s blood pressure dropped from 116/60 mm Hg to 88/50 mm Hg, indicating hypotension and potential septic shock. This is a life-threatening complication of meningococcal meningitis and requires immediate intervention to maintain perfusion.
• Temperature: The adolescent has a fever of 39° C (102.2° F), which contributes to metabolic stress and worsens neurologic symptoms. Once circulation is stabilized, managing hyperthermia helps decrease cerebral metabolic demand and discomfort.
Rationale for incorrect choices:
• Respiratory status: The respiratory rate and oxygen saturation are stable, with no signs of distress. This is not the most urgent priority compared to hypotension and shock risk.
• CSF results: While the findings are abnormal and confirm bacterial meningitis, they guide long-term treatment but do not pose an immediate threat like shock or hyperthermia.
• Oxygen saturation: Respirations remain 20/min with clear breath sounds and stable oxygen saturation, so there is no current evidence of respiratory compromise requiring immediate priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bowling: Bowling is a low-impact, non-contact sport that minimizes the risk of trauma and bleeding, making it a safe recreational activity for children with hemophilia. It allows participation while maintaining safety.
B. Gymnastics: Gymnastics carries a high risk of falls, joint stress, and injuries, which can lead to bleeding episodes in children with hemophilia. It is not a recommended sport due to the physical strain involved.
C. Basketball: Basketball involves frequent contact, collisions, and rapid movements that increase the risk of joint and soft tissue bleeding. For a child with hemophilia, this sport presents unnecessary risks.
D. Soccer: Soccer is also a high-contact sport with frequent falls, kicks, and collisions. The risk of trauma and internal bleeding makes it unsafe for children with hemophilia.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A","dropdown-group-3":"B"}
Explanation
Rationale for Correct Choices
• Give iron with vitamin C to increase absorption: Vitamin C enhances the solubility and bioavailability of iron, which is especially important for a child on a vegetarian diet where non-heme iron predominates. Taking iron with citrus juice or ascorbic acid reduces the risk of poor absorption and supports correction of anemia.
• Give iron through a straw to prevent staining of teeth: Liquid iron supplements can cause temporary discoloration of tooth enamel. Using a straw minimizes direct contact of iron with the teeth, helping to preserve dental appearance while ensuring the child still receives the full dose.
• Increase intake of iron-rich foods such as beans, leafy greens, and fortified cereals: A vegetarian child should be encouraged to consume a variety of non-heme iron foods. Combining these with vitamin C sources improves absorption and supports bone marrow production of healthy red blood cells.
Rationale for Incorrect Choices
• Give iron with milk to reduce stomach upset: Milk contains calcium and casein, both of which inhibit iron absorption, reducing the effectiveness of therapy.
• Administer iron on an empty stomach with no fluids: Iron is best absorbed on an empty stomach, but giving it without fluids increases gastric irritation and may cause poor adherence in children.
• Encourage brushing with baking soda after iron administration: Baking soda is abrasive and not recommended for children, as it may damage developing enamel while not significantly reducing iron staining.
• Mix iron with milk to reduce metallic taste: Mixing with milk impairs absorption, worsening anemia, and undermines the therapeutic purpose of supplementation.
• Restrict protein sources to avoid overworking bone marrow: Protein is essential for hemoglobin synthesis and red blood cell production; restricting it would worsen the child’s anemic state.
• Reduce iron-containing foods until medication is completed: Limiting dietary iron would prevent recovery from anemia and contradicts the goal of maximizing iron intake during supplementation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.