Nokea
What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that apply.)
- A. Isolation precautions
- B. Provision of brightly lit room
- C. Observation for increasing intracranial pressure
- D. Preparation for spinal tap
- E. Seizure precautions
Correct Answer: A,C,D,E
Rationale: All elements of nursing care listed in the options, except a brightly lit room, would be part of comprehensive care of a child with meningitis.
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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.
What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?
- A. The medication should be given on an empty stomach.
- B. Insomnia can be a significant side effect.
- C. Gums should be massaged regularly to prevent hyperplasia.
- D. Blood pressure should be closely monitored.
Correct Answer: C
Rationale: Dilantin can cause gum overgrowth, which can be minimized by regular massaging.
A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion?
- A. Sleepy but easily arousable
- B. Complaining of a stiff neck
- C. Cannot remember what happened to him
- D. Pupils react sluggishly to light
Correct Answer: C
Rationale: A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness, often accompanied by a loss of memory of the events.
An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented? (Select all that apply.)
- A. Parental education regarding prevention
- B. Respiratory support
- C. Cardiovascular support
- D. Controlled rewarming
- E. Adequate cerebral oxygenation
Correct Answer: B,C,D,E
Rationale: Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care.
Which situation would cause the nurse to suspect a hearing impairment?
- A. 3-month-old infant with a positive Moro (startle reaction) reflex
- B. 15-month-old toddler who is babbling
- C. 18-month-old toddler who is speaking one-syllable words
- D. 24-month-old toddler who communicates by pointing
Correct Answer: D
Rationale: The child who is not making verbal attempts by 24 months should undergo a complete physical examination.