Nokea
A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?
- A. Restlessness
- B. Sleepiness
- C. Nausea
- D. Anxiety
Correct Answer: B
Rationale: Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.
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What assessment does the school nurse recognize as the cardinal sign of a hyphema?
- A. Opacity of the lens
- B. A yellow-white reflex on the pupil
- C. A dark-red spot in front of the iris
- D. Inflamed mucous membranes of the eyelids
Correct Answer: C
Rationale: A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.
What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?
- A. The medication should be given on an empty stomach.
- B. Insomnia can be a significant side effect.
- C. Gums should be massaged regularly to prevent hyperplasia.
- D. Blood pressure should be closely monitored.
Correct Answer: C
Rationale: Dilantin can cause gum overgrowth, which can be minimized by regular massaging.
A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. Of which type of seizure is this behavior a characteristic?
- A. Absence
- B. Akinetic
- C. Myoclonic
- D. Complex partial
Correct Answer: A
Rationale: Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and may last only a few seconds.
What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?
- A. Use gestures and signs as much as possible.
- B. Let the child's parents communicate for her.
- C. Face the child and speak clearly in short sentences.
- D. Recognize that the child's ability to communicate will be on a 6-year-old child's level.
Correct Answer: C
Rationale: The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.
What statement by a patient's mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media?
- A. I will continue using the medication until symptoms are relieved.'
- B. I will share the medicine with siblings if their symptoms are the same.'
- C. I will give the medication with a glass of milk.'
- D. I will administer prescribed doses until all the medication is used.'
Correct Answer: D
Rationale: Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.