Which type of seizure involves a brief loss of awareness and minor motor movements such as eye blinking?
- A. Myoclonic seizure involves muscle movement and not just loss of awareness.
- B. Febrile seizures occur when the child's temperature is excessively elevated and usually includes tonic-clonic muscle movement.
- C. An absence seizure is a generalized seizure (involving loss of awareness) that might involve minor motor movements (e.g., eye blinking). The child appears to be staring.
- D. Atonic means absence of tone and would involve loss of muscle control and not eye blinking, which requires muscle control.
Correct Answer: C
Rationale: Absence seizures are characterized by brief loss of awareness and minor motor movements like eye blinking, with the child appearing to stare.
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The nurse is caring for a client six (6) hours postoperative right total knee replacement. Which data should the nurse report to the surgeon?
- A. A total of 100 mL of red drainage in the autotransfusion drainage system.
- B. Pain relief after using the patient-controlled analgesia (PCA) pump.
- C. Cool toes, distal pulses palpable, and pale nailbeds bilaterally.
- D. Urinary output of 60 mL of clear yellow urine in three (3) hours.
Correct Answer: C
Rationale: Cool toes and pale nailbeds suggest vascular compromise, requiring surgeon notification. Expected drainage, pain relief, and low urine output are less urgent.
During a physical examination of the 1-month-old, the nurse notes that the infant has blue sclerae. The nurse should further assess for signs and symptoms of which disorder?
- A. Juvenile rheumatoid arthritis (JRA)
- B. Tay-Sachs disease
- C. Duchenne muscular dystrophy (DMD)
- D. Osteogenesis imperfecta (OI)
Correct Answer: D
Rationale: Blue sclerae are a hallmark of osteogenesis imperfecta due to thin connective tissue.
The child with an SCI is prescribed baclofen 5 mg tid orally to treat muscle spasticity. How many tablets should the nurse administer for one dose if 20-mg tablets are available?
Correct Answer: 0.25
Rationale: 5 mg divided by 20 mg per tablet equals 0.25 tablets per dose.
Which is the nurse's best explanation regarding the goal of surgery for an adolescent requiring surgical treatment for scoliosis?
- A. "The surgery will allow you to grow to be taller."
- B. "The surgery will decrease the recurrence of pain."
- C. "The surgery will prevent problems with breathing."
- D. "The surgery will allow your clothes to fit you better."
Correct Answer: C
Rationale: Scoliosis surgery aims to correct spinal deformity and prevent respiratory complications.
What should the nurse do after noting serosanguineous drainage on the cast of a child with myelodysplasia post-TEV repair?
- A. Cut a window where the drainage is seeping through the cast.
- B. Petal the cast to minimize skin irritation and decrease leakage.
- C. Measure the area of drainage on the cast and document this.
- D. Telephone the surgeon to report the serosanguineous drainage.
Correct Answer: C
Rationale: Measuring and documenting the drainage allows monitoring without compromising the cast's integrity.
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