Nokea
What will the nurse include when documenting a grand mal seizure? (Select all that apply.)
- A. Presence of incontinence
- B. Current dose of antispasmodic medication
- C. Activity level prior to and following seizure
- D. Level of consciousness following seizure
- E. Length of seizure
Correct Answer: A,C,D,E
Rationale: Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure.
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Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which statement by the parents alerts the nurse they need further instruction?
- A. We dress our son every morning for school.'
- B. Our son participates in the Special Olympics every year.'
- C. Our son attends play therapy at a center close to home.'
- D. We attend a support group once a week.'
Correct Answer: A
Rationale: The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should not 'take over' projects.
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.
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.
The nurse urges the mother of a 6-month-old child to get her child inoculated with Haemophilus influenzae type B. What does this immunization protect against?
- A. Encephalitis
- B. Influenza
- C. Bacterial meningitis
- D. Otitis media
Correct Answer: C
Rationale: H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.
Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.)
- A. Hypersensitivity to noise
- B. Irritability
- C. Ecchymotic ear canal
- D. Rolls head from side to side
- E. Temperature of 39.4?°C (103?°F)
Correct Answer: B,D,E
Rationale: Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.