Nokea
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.
You may also like to solve these questions
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.
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.
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.
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.
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.