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 ["B","C"]
Explanation
A. "This drug won't decrease the effectiveness of their oral contraceptive medication.": Phenytoin induces hepatic enzymes, which increase the metabolism of oral contraceptives and reduce their effectiveness.
B. "We will need to periodically have their blood drawn to check phenytoin levels.": Phenytoin has a narrow therapeutic index, and blood levels must be monitored to avoid subtherapeutic dosing or toxic effects such as ataxia, confusion, or nystagmus.
C. "This medication may cause their eyes to move quickly back and forth at times.": Nystagmus is a known dose-related adverse effect of phenytoin, especially at higher levels. Recognizing this side effect indicates understanding of possible neurologic manifestations of toxicity.
D. "They will need to take 400 international units (IU) of vitamin E while on this medication.": Vitamin E supplementation is not required for adolescents taking phenytoin. Nutritional support may focus more on maintaining adequate folic acid and vitamin D.
E. "There is nothing we can do to minimize overgrowth of their gum tissue.": Gingival hyperplasia is a common side effect of phenytoin, but it can be minimized with proper oral hygiene such as regular toothbrushing, flossing, and dental visits.
Correct Answer is B
Explanation
A. Give the child a candy bar: A candy bar contains fat along with sugar, which delays absorption of glucose. In a hypoglycemic episode, the goal is to provide a rapidly absorbed carbohydrate source to quickly raise blood glucose.
B. Give the child 3 to 6 oz of orange juice: Orange juice provides a fast-acting carbohydrate that is quickly absorbed, making it the most appropriate treatment for mild hypoglycemia in a conscious child. It helps correct symptoms like tremors and diaphoresis promptly.
C. Administer glucagon to the vastus lateralis: Glucagon is indicated for severe hypoglycemia when the child is unconscious, unable to swallow, or having seizures. Since the child is awake with altered mental status but still able to take oral fluids, glucagon is not the first choice.
D. Administer D5W intravenous fluids: IV dextrose is also reserved for severe hypoglycemia when oral intake is not possible. In this scenario, giving oral glucose is safer and less invasive since the child can still drink.
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