A 12-year-old child is being admitted to the pediatric unit. What is the priority nursing action based on these the data below? Vital signs: T: 104F (40C) P: 89, R: 30, B/P: 80/42 Nurse's notes: Difficult to arouse, c/o headache, emesis x2, exhibiting nuchal rigidity, slight petechiae noted on distal extremities, lumbar puncture completed with results of elevated WBCs in CSF, decreased glucose in CSF.

Administer antipyretic therapy

Place the child in a lateral Sims position

Place the child on droplet precautions

Reduce all environmental stimuli

Answer and Explanation

The Correct Answer is C

A. Administer antipyretic therapy is appropriate to help reduce fever, but it is not the first priority. The child’s vital signs indicate a high fever and signs of possible meningitis, and intervention to prevent further complications or the spread of infection should take precedence.

B. Place the child in a lateral Sims position is unnecessary in this case. A lateral Sims position is typically used to prevent aspiration during vomiting, but it is not the priority for this child. The focus should be on infection control and stabilizing the child’s condition.

C. Place the child on droplet precautions is the correct priority. The child is showing signs of possible bacterial meningitis, which is a highly contagious infection. Droplet precautions are necessary to prevent transmission of the infection to other individuals.

D. Reduce all environmental stimuli may be helpful for a child with a neurological condition, but it is not the first priority in this case. The priority is preventing the spread of infection while further stabilizing the child’s condition.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. Sickled red blood cells are flexible, making it easier for these cells to travel through small vessels is incorrect. Sickled red blood cells are rigid and inflexible, which makes it difficult for them to pass through small blood vessels, contributing to blockages and reduced oxygen delivery.

B. Sickled red blood cells are c-shaped and tend to stick together more easily is correct. Sickled red blood cells have an abnormal, crescent or "C" shape, and they stick together, which can cause clumping and block blood flow in small vessels, leading to pain and organ damage.

C. Sickled red blood cells have a long-life span. Therefore, they circulate in the blood longer than healthy cells is incorrect. Sickled red blood cells have a shortened life span (about 10-20 days) compared to normal red blood cells, which typically last 120 days, leading to a higher rate of cell destruction and anemia.

D. Sickled red blood cells are rigid, making it difficult for the cells to travel through smaller vessels is correct. The rigidity of sickled cells prevents them from easily moving through small blood vessels, causing occlusions, pain, and organ damage.

E. Sickled red blood cells have a short life span which decreases the number of red blood cells circulating in the blood is correct. Due to their short life span, sickled cells are destroyed more quickly, leading to anemia and reduced oxygen-carrying capacity in the blood.

A. Respiratory rate B. Blood pressure C. Body weight D. Skin integrity

Correct Answer is C

Explanation

A. Respiratory rate can be influenced by many factors, including fever or anxiety, and is not the most reliable indicator of fluid loss.

B. Blood pressure may change with severe dehydration, but it can be a late sign, and other factors (like shock) can also affect blood pressure, so it's not the most reliable early indicator.

C. Body weight is the most reliable and sensitive indicator of fluid loss, as even small changes in weight reflect changes in hydration status. Monitoring weight helps assess fluid loss accurately.

D. Skin integrity can be affected by dehydration, but it's not the most reliable indicator of fluid loss. It may take longer to show visible signs such as dry skin or poor turgor.

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Naxlex Comprehensive Predictor Exams

A nurse is providing care to an infant newly diagnosed with sickle cell anemia. The infant's parents ask the nurse to describe what sickled red blood cells are and how they affect blood flow. Which of the following statements should the nurse include in the discussion? (Select All that Apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss?

Correct Answer is C

Explanation

When administering oral iron supplements to a client with anemia, which nursing action is most important to ensure optimal absorption of the medication?

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

A nurse is caring for a child who has increasing manifestations of fever, headache, stiff neck, and rash. Which of the following diagnostic tests should the nurse expect the health care provider to order?

A nurse is assessing a pediatric client who is exhibiting manifestations of rhabdomyosarcoma. In which area of the body should the nurse expect to find a tumor?

The nurse is monitoring a 7-year-old child post-surgical resection of a supratentorial (cerebral) brain tumor. Which vital sign finding indicates Cushing's triad?

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