Nokea
A nurse is caring for an adolescent client who is receiving carbamazepine (Tegretol) for partial seizure disorder. Which of the following statements by the adolescent's parent is the priority for the nurse to address?
- A. He takes his medication between meals with water.
- B. He only sleeps about 5 hours each night.
- C. He seems to be getting a lot more bumps and bruises lately.
- D. He has not been eating as much lately.
Correct Answer: C
Rationale: Increased bruising can indicate thrombocytopeniaa potential side effect of carbamazepine which can lead to serious bleeding issues.
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A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Restrain the child's arms.
- B. Insert a padded tongue blade into the child's mouth.
- C. Place the child in a side-lying position.
- D. Elevate the child's legs on a pillow.
Correct Answer: C
Rationale: This helps maintain an open airway and allows for drainage of saliva or vomit reducing the risk of aspiration.
A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Absent plantar reflexes
- B. Inwardly turned foot on the affected side
- C. Asymmetric thigh folds
- D. Lengthened thigh on the affected side
Correct Answer: C
Rationale: Asymmetric thigh folds is a common finding in DDH.
Medical History
Nurses notes:
Vital Signs:
Laboratory results:
0900:
Temperature 36.8° C (98.2° F)
Heart rate 80/min
Respiratory rate 22/min
Blood pressure 102/78 mm Hg
SaO2 is 94% on room air
Upon review of the child's electronic medical record (EMR), the nurse should determine the child is at risk for developing which of the following conditions? Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is at risk for developing Increased seizure activity pneumonia liver failure Steven-johnson syndrome pneumothorax due to phenytoin level cough skin rash liver enzymes lung sounds.
- A. Increased seizure activity
- B. pneumonia
- C. liver failure
- D. Steven-johnson syndrome
- E. pneumothorax
Correct Answer: A
Rationale: The child's phenytoin level is 6 mcg/mL which is below the therapeutic range of 10-20 mcg/Ml, increasing the risk of more seizures.
A nurse is preparing to administer acetaminophen 15 mg/kg PO to a preschool child for fever. The child weighs 30 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 6.4 mL
- B. 5.4 mL
- C. 7.4 mL
- D. 4.4 mL
Correct Answer: 6.4
Rationale: Calculation: 30 lb × 0.454 kg/lb = 13.62 kg; 15 mg/kg × 13.62 kg = 204.3 mg; 204.3 mg ÷ 160 mg/5 mL = 6.4 mL.
A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?
- A. Drink eight glasses of fluid daily.
- B. Maintain an updated haemophilus influenza type B immunization.
- C. Assume postural drainage positions every 6 hr.
- D. Avoid playground activities at school.
Correct Answer: A
Rationale: Maintaining hydration is crucial in preventing sickle cell crises as it helps to keep the blood less viscous.