Nokea
A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action?
- A. Take vital signs.
- B. Establish an intravenous line.
- C. Perform rapid neurologic assessment.
- D. Maintain a patent airway.
Correct Answer: D
Rationale: When a child with a history of seizures presents in status epilepticus, the priority nursing action is to maintain a patent airway. This is crucial to ensure proper oxygenation and ventilation. Establishing an intravenous line and performing other assessments are important but maintaining a patent airway takes precedence to prevent hypoxia and ensure the child's safety.
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During the first two years of life, patients with bronchopulmonary dysplasia requiring rehospitalization are most likely to be diagnosed with:
- A. electrolyte disturbances.
- B. immune deficiencies.
- C. pulmonary hypertension.
- D. respiratory tract infections.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A newborn's parents are being taught about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should be included?
- A. Place the infant in a prone position to sleep.
- B. Allow the infant to sleep on a large pillow.
- C. Use a soft mattress in the infant's crib.
- D. Give the infant a pacifier at bedtime.
Correct Answer: D
Rationale: The correct instruction to prevent SIDS is to give the infant a pacifier at bedtime. The use of a pacifier while the infant is sleeping is associated with a decreased risk of SIDS. Other recommended preventive measures include placing the infant on their back to sleep, using a firm mattress in the crib, and avoiding soft bedding or pillows.
A toddler in the emergency department has partial thickness burns on his right arm. Which of the following actions should the nurse take?
- A. Insert a nasogastric tube
- B. Initiate prophylactic antibiotic therapy
- C. Cleanse the affected area with mild soap and water
- D. Apply a topical corticosteroid to the affected area
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Marge is a 2-year-old girl who does not sit and eat at mealtimes but rather brings food to many rooms, eats a few bites, and drops it. Her parents report that she is a 'fussy eater.' Marge is significantly below weight for her age. She does not have any oral motor structure abnormalities, but eats only certain foods with the same texture. Which intervention strategy would be best to address the environmental context?
- A. Prolong mealtimes and eliminate all snacks
- B. Provide high-calorie snacks and meals at the table throughout the day
- C. Allow Marge to eat whenever and wherever she wants in the house
- D. Require Marge to eat everything on her plate and at snack
Correct Answer: B
Rationale: In the case of Marge, who exhibits selective eating habits and struggles with weight gain, providing high-calorie snacks and meals at the table throughout the day can be an effective intervention. This strategy can help increase her food intake in a structured environment, promoting healthier eating habits and potentially addressing her below-average weight status. By offering calorie-dense foods at designated meal times, Marge may be more likely to consume the necessary nutrients to support her growth and development, ultimately improving her overall health.
A teacher states to the school nurse, 'I have a student who will often just stare at me for 15 seconds after asking a question; then the student blinks and asks me to repeat the question. Should I be concerned?' Which should the nurse include in the response to the teacher?
- A. The child has a crush on the teacher.
- B. The child has increased intracranial pressure.
- C. The child may have had a head injury.
- D. The child is experiencing absence seizures.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.