Nokea
The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?
- A. He has been taking long naps for a week.'
- B. He has had an ear infection for the past 2 days.'
- C. He has been eating more red meat lately.'
- D. He seems to be going to the bathroom more frequently.'
Correct Answer: B
Rationale: He has had an ear infection for the past 2 days.' Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention.
You may also like to solve these questions
The client with Cushing's disease will most likely exhibit signs of:
- A. Hypokalemia
- B. Hypernatremia
- C. Hypocalcaemia
- D. Hypermagnesemia
Correct Answer: A
Rationale: Cushing's disease causes hypercortisolism, leading to hypokalemia due to increased potassium excretion. Hypernatremia , hypocalcaemia , and hypermagnesemia are not typical in Cushing's disease.
A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively?
- A. Assessment of the child's emotional maturity level
- B. Auscultating for adventitious breath sounds
- C. Monitoring blood pressure closely
- D. Reinforcing instructions not to palpate the abdomen
Correct Answer: D
Rationale: Avoiding abdominal palpation (D) prevents tumor rupture in Wilms tumor, a critical pre-operative priority. Emotional assessment (A), lung sounds (B), and BP monitoring (C) are important but secondary.
The home health nurse is providing long-term care to several clients. Which are examples of inappropriately crossing professional boundaries? Select all that apply.
- A. Accepting a birthday gift of a gold bracelet from a client
- B. Offering to pray together if a client so wishes
- C. Sending a sympathy card to family after a client dies
- D. Soliciting a wealthy client to invest in a company
- E. Staying after work hours and drinking wine with a client
Correct Answer: A,D,E
Rationale: Accepting expensive gifts (A), soliciting investments (D), and socializing with alcohol (E) violate professional boundaries. Offering to pray (B) is acceptable if client-initiated, and a sympathy card (C) is appropriate.
The nurse is preparing to administer an anticholinergic medication to a client with irritable bowel syndrome. Which of the following findings would require follow-up prior to administering the medication?
- A. bladder scan that shows 650 mL of urine after voiding
- B. history of age-related macular degeneration
- C. frequent loose stools in the past 24 hours
- D. reports of fatigue and drowsiness
Correct Answer: A
Rationale: Anticholinergics can worsen urinary retention, so 650 mL post-void residual (A) requires follow-up. Macular degeneration (B), loose stools (C), and fatigue (D) are not contraindications.
The nurse is caring for a client who has bleeding esophageal varices. What should the nurse expect might develop in this client? Select all that apply.
- A. Confusion
- B. Tarry stools
- C. Lower abdominal pain and pressure
- D. High blood pressure
- E. Tremors
- F. Hallucinations
Correct Answer: A,B
Rationale: Bleeding varices cause blood loss, leading to tarry stools (melena) from digested blood and confusion from hepatic encephalopathy due to liver dysfunction. Abdominal pain, hypertension, tremors, or hallucinations are less directly related.