6-year-old child.

Vomited 3 times in the past 24 hr. Irritable behavior for the past 24 hr. The respiratory infection started 3 days ago.

Brudzinski's and Kernig's signs are positive.

Vital Signs.

Respiratory rate 28/min.

Pulse rate 120/min.

BP 108/64 mm Hg. Pain level of 6 on a scale from 0 to 10. Medication Administration Record.

Vancomycin 300 mg IV q 6 hr following blood cultures.

Acetaminophen 240 mg PO q 6 hr PRN fever.

A nurse is planning care for a child during admission to the facility.

Which of the following actions should the nurse take first?

Obtain a prescription for pain medication.

Initiate seizure precautions.

Collect blood cultures.

Transport the child to obtain a CT scan.

Answer and Explanation

The Correct Answer is B

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Correct Answer is A

Explanation

Explanation: Evisceration is a surgical emergency that occurs when the abdominal contents protrude through the incision site. The nurse should instruct the client to lie supine with his knees flexed to reduce tension on the wound and prevent further damage.

The nurse should also cover the wound with a moist sterile dressing and notify the surgeon immediately. Positioning the client in semi-Fowler's position, covering the wound with a dry sterile dressing, or covering the wound with a transparent dressing are not appropriate actions for evisceration.

A. Wear clothing with zippers instead of buttons. B. Place locks at the tops of exterior doors. C. Replace the carpet with hardwood floors. D. Encourage physical activity prior to bedtime.

Correct Answer is B

Explanation

Choice A rationale:

Wearing clothing with zippers instead of buttons does not address the safety concerns related to Alzheimer's disease. This choice does not ensure the client's safety or prevent wandering, which are common issues in Alzheimer's patients.

Choice B rationale:

Placing locks at the tops of exterior doors is essential for the safety of clients with Alzheimer's disease. Alzheimer's patients often have a tendency to wander and may become disoriented, putting them at risk of getting lost or injured outside the home. Proper locks can prevent them from leaving the house unsupervised.

Choice C rationale:

Replacing the carpet with hardwood floors may reduce the risk of falls but does not specifically address the safety concerns related to Alzheimer's disease. It is important to focus on measures that prevent wandering and ensure the client's safety in various situations.

Choice D rationale:

Encouraging physical activity prior to bedtime is a good practice for promoting sleep in older adults but does not directly address the safety concerns of Alzheimer's patients. Safety measures, such as securing doors, supervising the client, and preventing wandering, are more crucial in this context.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an abdominal surgical incision and notes an evisceration. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A home health nurse is planning care for a client who has Alzheimer's disease.Which of the following actions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse manager is addressing reports of conflict within a nursing unit.The nurse should identify which of the following situations as an example of interpersonal conflict?

A school nurse is performing scoliosis screenings.The nurse should recognize which of the following clinical manifestations as an indication of scoliosis?

A nurse is planning teaching for a client who has a newly implanted implantable cardioverter-defibrillator.Which of the following information should the nurse include?

A nurse is reviewing the medical records of four clients.The nurse should identify that which of the following client findings requires follow-up care?

A nurse is implementing seizure precautions for a client who has had a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan of care?

A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the highest in potassium?

A nurse in an emergency department is performing an assessment on a client who reports being sexually assaulted. Which of the following actions should the nurse take first?