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A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?
- A. Maintain seizure precautions.
- B. Document intake and output.
- C. Administer antibiotics when available.
- D. Reduce environmental stimuli.
Correct Answer: C
Rationale: Maintain seizure precautions: While seizures can occur as a complication of bacterial meningitis, maintaining seizure precautions is not the nurse's priority at this stage. Prompt administration of antibiotics to address the underlying infection takes precedence over seizure precautions. Document intake and output: Documenting intake and output is an important nursing responsibility, but it is not the priority when a child is suspected of having bacterial meningitis. The immediate priority is to initiate antibiotic therapy to treat the infection and prevent further complications. Administer antibiotics when available: Administering antibiotics is the priority in the care of a child with suspected bacterial meningitis. Antibiotics are crucial for treating the infection and preventing its progression to reduce the risk of serious complications such as brain damage or death. Reduce environmental stimuli: While reducing environmental stimuli can help manage symptoms and discomfort in a child with bacterial meningitis, it is not the priority at this time. Initiating antibiotic therapy is essential to address the underlying infection, which takes precedence over environmental stimuli reduction.
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A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Move the child into a side-lying position.
- B. Place a pillow under the child's head.
- C. Time the seizure.
- D. Remove the child's eyeglasses.
Correct Answer: A
Rationale: Move the child into a side-lying position: This action is crucial during a seizure with vomiting to prevent aspiration. Placing the child on their side helps ensure that any vomit can easily exit the mouth and reduces the risk of choking or aspiration into the lungs. Place a pillow under the child's head: While providing comfort is important, it is not the priority during a seizure with vomiting. Placing a pillow under the child's head might elevate the head slightly, but it doesn't address the risk of aspiration, which is the primary concern. Time the seizure: Timing the seizure is important for documentation and to monitor the duration of the seizure. However, it is not the priority during the active phase of the seizure, especially when vomiting is occurring. Remove the child's eyeglasses: Removing the child's eyeglasses is not a priority during a seizure with vomiting. While it's important to prevent injury, particularly to the eyes, during a seizure, the immediate concern is addressing the risk of aspiration caused by vomiting.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Monitor the client's hemoglobin level
- B. Restrain the client's extremities
- C. Place the client in a prone position
- D. Record the time and length of the seizure
Correct Answer: D
Rationale: Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Place the child in a side-lying position.
- B. Restrain the child's arms.
- C. Elevate the child's legs on a pillow.
- D. Insert a padded tongue blade into the child's mouth.
Correct Answer: A
Rationale: Place the child in a side-lying position. This is the correct action to take during a seizure to prevent aspiration and maintain an open airway. Placing the child in a side-lying position helps to prevent choking or aspiration if vomiting occurs and allows saliva or other fluids to drain out of the mouth instead of being inhaled into the lungs. Restrain the child's arms. Restraining the child's arms is not recommended during a seizure. It can potentially cause injury to the child or the person trying to restrain them. It may also exacerbate muscle spasms and increase the risk of injury during the seizure. Elevate the child's legs on a pillow. Elevating the child's legs on a pillow is not necessary during a seizure and is not a recommended intervention. It does not address the immediate needs of the child during a seizure, such as maintaining an open airway and preventing injury. Insert a padded tongue blade into the child's mouth. Inserting anything into the child's mouth during a seizure, including a tongue blade, is strongly discouraged. It can cause injury to the child's teeth, gums, or oral tissues and increase the risk of choking or aspiration. It may also result in the nurse getting bitten during the seizure. Maintaining a clear airway and ensuring the child's safety are the priorities during a seizure, and inserting objects into the mouth can interfere with these goals.
A nurse is caring for a child who has Hirschsprung disease. Which of the following findings should the nurse expect?
- A. Ridged abdomen
- B. Ribbonlike, foul-smelling stools
- C. Projectile vomiting
- D. Chronic hunger
Correct Answer: B
Rationale: Ridged abdomen - This finding is not typically associated with Hirschsprung disease. Instead, the abdomen may appear distended or bloated due to the accumulation of stool in the colon. Ribbonlike, foul-smelling stools - This is a characteristic finding in Hirschsprung disease. Because the affected portion of the colon lacks nerve cells (ganglion cells) responsible for peristalsis, stool movement is impaired, leading to the passage of narrow, ribbonlike stools. These stools may also have a foul odor due to bacterial overgrowth in the affected area. Projectile vomiting - Projectile vomiting is not a common finding in Hirschsprung disease. It is more commonly associated with conditions such as pyloric stenosis or gastroesophageal reflux. Chronic hunger - Chronic hunger is not a typical finding in Hirschsprung disease. Instead, affected infants may experience feeding difficulties, constipation, and failure to thrive due to the obstruction of stool in the colon. They may also exhibit symptoms such as abdominal distention, vomiting, and refusal to feed.
A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Increased appetite
- C. Mucus in stools
- D. Jaundice
Correct Answer: C
Rationale: Drooling - Drooling is not typically associated with intussusception. Intussusception is a condition where one portion of the intestine telescopes into another, leading to bowel obstruction and subsequent symptoms such as abdominal pain, vomiting, and 'currant jelly' stools. Increased appetite - Increased appetite is unlikely in a toddler with intussusception. Instead, affected toddlers may experience symptoms such as abdominal pain, vomiting, and lethargy, which can lead to decreased appetite. Mucus in stools - Mucus in stools is a characteristic finding in intussusception. As the telescoping of the intestine causes irritation and inflammation, mucus may be passed in the stool along with blood and, in some cases, a characteristic 'currant jelly' appearance. Jaundice - Jaundice is not a typical manifestation of intussusception. It may be present in conditions affecting the liver or bile ducts, such as biliary atresia or obstructive jaundice, but it is not a direct symptom of intussusception.