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An adolescent has just had a generalized seizure and collapsed in the school nurse's office. When should the nurse should call 911?
- A. The seizure lasts more than 5 minutes.
- B. The child is sleepy and lethargic after the seizure.
- C. The child vomited at the onset of the seizure.
- D. The child is confused and has slurred speech after the seizure.
Correct Answer: A
Rationale: If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.
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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 might the nurse explain as a common treatment for amblyopia?
- A. Patching the good eye to force the brain to use the affected eye
- B. Patching the affected eye to allow the refractory muscles to rest
- C. Using glasses that will slightly blur the image for the good eye
- D. Using corticosteroids to treat inflammation of the optic nerve
Correct Answer: A
Rationale: Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors.
What symptom leads the nurse caring for a 5-month-old child with viral influenza to suspect the development of Reye's syndrome?
- A. Respirations drop from 18 to 14 breaths/minute
- B. Falling asleep after feeding
- C. Sudden vomiting without effort
- D. Development of a macular rash
Correct Answer: C
Rationale: A child with a viral infection is at risk for Reye's syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness.
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.
Which assessment finding in a child with meningitis should be reported immediately?
- A. Irregular respirations
- B. Tachycardia
- C. Slight drop in blood pressure
- D. Elevated temperature
Correct Answer: A
Rationale: Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately, because they could indicate increased intracranial pressure.