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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Laxatives are not typically used for sickle cell crisis unless the client is experiencing constipation, which is unrelated to the crisis itself.
B. Thyroid replacement medications are used for hypothyroidism and would not be a first-line treatment for sickle cell crisis.
C. Diuretics may be used in conditions like heart failure or kidney disease, but they are not indicated for sickle cell crisis and may worsen dehydration.
D. Pain medications are the correct intervention during a sickle cell crisis. The crisis involves severe pain due to the sickling of red blood cells blocking blood flow to tissues. Opioids like morphine and hydromorphone are commonly administered to manage the severe pain.
Correct Answer is A
Explanation
A. Administering anti-seizure medication is the priority. In a child experiencing status epilepticus, immediate administration of anti-seizure medication is essential to stop the seizure activity and prevent further neurological damage. The primary goal is to terminate the seizure as quickly as possible.
B. Restraining the child to prevent injury is not the priority. Restraining a child during a seizure can increase the risk of injury and is not recommended. Instead, protecting the child from harm by placing them in a safe position is more appropriate.
C. Providing emotional support to the child's family is important, but it is not the immediate priority during the acute phase of status epilepticus. The child's immediate safety and health take precedence.
D. Documenting the seizure activity should be done after ensuring that the seizure has been controlled. Accurate documentation is important, but it is secondary to the intervention needed to stop the seizure.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.