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What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
- A. Assist the child to bed and then go for help.
- B. Move objects out of the child's immediate area.
- C. Stick a padded tongue blade between the child's teeth.
- D. Manually restrain the child.
Correct Answer: B
Rationale: During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.
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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.
The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?
- A. Athetoid
- B. Ataxic
- C. Spastic
- D. Mixed
Correct Answer: C
Rationale: Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.
A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?
- A. Restlessness
- B. Sleepiness
- C. Nausea
- D. Anxiety
Correct Answer: B
Rationale: Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.
What assessment does the school nurse recognize as the cardinal sign of a hyphema?
- A. Opacity of the lens
- B. A yellow-white reflex on the pupil
- C. A dark-red spot in front of the iris
- D. Inflamed mucous membranes of the eyelids
Correct Answer: C
Rationale: A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.
The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.)
- A. Encourage books with large type.
- B. Words in books should be closely spaced.
- C. Provide adequate lighting without glare.
- D. Be sure desks and chairs are adequate height.
- E. Instruct child to squint when reading.
Correct Answer: A,C,D
Rationale: Children who are beginning to read need books with large type in which the letters are spaced far apart.