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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.
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A 24 month old comes into the clinic to get his first flu vaccination. The nurse notices what food allergy in the patient's chart that would make this vaccine contraindicated?
- A. Gelatin
- B. Peanuts
- C. Eggs
- D. Bee Venom
Correct Answer: C
Rationale: Gelatin: Gelatin is sometimes used as a stabilizer in vaccines, including some flu vaccines. Individuals with severe gelatin allergies may need to avoid vaccines containing gelatin. However, egg allergy is more common and directly relevant to the contraindication for flu vaccination. Peanuts: Peanuts are not typically used in the production of flu vaccines. Peanut allergies are not a contraindication for flu vaccination unless the person also has an egg allergy or another contraindication. Eggs: Flu vaccines are commonly produced using chicken eggs. Therefore, individuals with a severe egg allergy should avoid flu vaccines, as they may experience an allergic reaction. This is especially important for young children, as they may be more prone to severe allergic reactions. Bee Venom: Bee venom is not an ingredient in flu vaccines. While it's essential to consider allergies to various substances when administering vaccines, bee venom allergy does not impact the safety of flu vaccination.
The nurse is providing discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicate that further teaching is necessary?
- A. I give him medication so he'll be comfortable.
- B. I check his voiding to be sure there's no problem.
- C. I check his temperature.
- D. I'll let him decide when to return to his play activities.
Correct Answer: D
Rationale: I give him medication so he'll be comfortable.' - This statement indicates that the parents are providing medication to ensure the child's comfort after the procedure, which is an appropriate action. It suggests that the parents are attentive to the child's needs postoperatively. 'I check his voiding to be sure there's no problem.' - Checking the child's voiding is important postoperatively to ensure there are no urinary retention issues or other complications related to urination. This statement reflects appropriate postoperative care and monitoring. 'I check his temperature.' - Monitoring the child's temperature is also a good practice postoperatively to watch for signs of infection or other complications. This statement indicates that the parents are attentive to signs of potential postoperative issues. 'I'll let him decide when to return to his play activities.' - This statement suggests that the parents plan to let the child decide when to resume play activities after the surgery. However, after a surgical procedure like orchiopexy, it's important for parents to follow specific guidelines provided by healthcare providers regarding activity restrictions and return to normal activities. Allowing the child to decide may not align with the recommended postoperative care plan.
When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most important to avoid which of the following?
- A. Measuring the child's chest circumference
- B. Palpating the child's abdomen
- C. Measuring the child's occipitofrontal circumference
- D. Placing the child in an upright position
Correct Answer: B
Rationale: Measuring the child's chest circumference: Measuring the chest circumference may not directly aid in the assessment of Wilm's tumor. While it's important for assessing respiratory conditions or monitoring growth, it's not a primary assessment for Wilm's tumor, which primarily affects the abdomen. Palpating the child's abdomen: This is an essential action in assessing for Wilm's tumor. The nurse should carefully palpate the abdomen to check for any masses, swelling, or tenderness, as these could be indicative of the tumor. Measuring the child's occipitofrontal circumference: This measurement pertains to the head circumference and is not directly related to the assessment of Wilm's tumor. While it's important for monitoring head growth and development, it's not a priority when assessing for Wilm's tumor. Placing the child in an upright position: Placing the child in an upright position may be necessary for certain assessments or procedures, but it's not directly related to assessing for Wilm's tumor. The focus should primarily be on abdominal assessment and palpation to detect any signs of the tumor.
A nurse is collecting data from an infant who has gastroesophageal reflux. Which of the following findings should the nurse expect? (Select the 3 that apply.)
- A. Wheezing
- B. Rigid abdomen
- C. Pallor
- D. Weight loss
- E. Vomiting
Correct Answer: A,D,E
Rationale: A. Wheezing: Wheezing is a common symptom associated with asthma, which can be exacerbated by gastroesophageal reflux (GER) in infants. GER occurs when stomach contents flow back into the esophagus, leading to irritation and inflammation of the airways. This inflammation can cause wheezing sounds during breathing, especially if the refluxed material reaches the lower respiratory tract. B. Rigid abdomen: While gastroesophageal reflux (GER) primarily affects the upper gastrointestinal tract, it typically does not cause a rigid abdomen. A rigid abdomen may indicate other underlying gastrointestinal issues such as bowel obstruction, intussusception, or peritonitis. These conditions are not typically associated with GER in infants. C. Pallor: Pallor, or paleness of the skin, is not a common symptom of gastroesophageal reflux (GER) in infants. GER primarily affects the upper gastrointestinal tract and is characterized by symptoms such as spitting up, regurgitation, and irritability. Pallor may be indicative of other health issues such as anemia or circulatory problems but is not directly related to GER. D. Weight loss: Weight loss can occur in infants with gastroesophageal reflux (GER) if frequent vomiting leads to inadequate intake of nutrients. However, it is not a direct symptom of GER itself. Infants with GER may experience feeding difficulties, irritability, and discomfort associated with feeding, which can contribute to poor weight gain over time if not managed effectively. E. Vomiting: Vomiting is a common symptom of gastroesophageal reflux (GER) in infants. It occurs when stomach contents flow back up into the esophagus and sometimes out of the mouth. Infants with GER may spit up or vomit frequently after feeding or during burping, which can lead to discomfort and irritability. Vomiting may also contribute to poor weight gain and nutritional deficiencies if not managed effectively.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Change to cloth diapers until the skin is healed.
- B. Use a moisturizer to wipe urine from the skin.
- C. Apply a light layer of talcum powder with each diaper change.
- D. Expose the excoriated area to hot air frequently.
Correct Answer: B
Rationale: While some parents may prefer cloth diapers, they can retain moisture and irritants. Disposable diapers with good absorbency are often preferred in managing diaper dermatitis. Using a gentle moisturizer to clean the skin can help protect the infant's skin and maintain its barrier function, especially in cases of diaper dermatitis. Moisturizers help soothe and heal the affected area by providing hydration and protection. Talcum powder is not recommended due to the risk of inhalation, which can cause respiratory issues. Additionally, powders can clump and worsen skin irritation. Exposing the skin to hot air can dry out the skin and worsen irritation. It's better to allow the area to air-dry naturally or use a cool blow dryer on a low setting.