A child with a brain tumor has a decreased respiratory hate and is less responsive to verbal commands than he was when the nurses assessed the client the previous hour. What should the nurse do next?
Raise the head of the bed
Notify the health care provider (HCP)
Obtain an oximeter reading
Implement seizure precautions
The Correct Answer is B
A. Raising the head of the bed may help with respiratory effort but does not address the underlying issue of decreased responsiveness. Immediate assessment and intervention are necessary.
B. Notifying the healthcare provider is critical as the child’s decreased responsiveness and respiratory rate indicate a potential deterioration in condition that requires prompt medical evaluation.
C. While obtaining an oximeter reading can provide useful information about oxygenation, the priority is to notify the HCP about the change in the child's neurological status.
D. Implementing seizure precautions is important for a child with a brain tumor, but the immediate concern is the change in responsiveness, necessitating HCP notification first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An oral rehydration solution is specifically designed to replace lost fluids and electrolytes, making it the best choice for children recovering from gastroenteritis.
B. Water alone does not provide the necessary electrolytes and may not effectively rehydrate the child.
C. Broth can provide some hydration but lacks the specific electrolyte balance found in oral rehydration solutions.
D. Diluted apple juice is not as effective for rehydration as a balanced oral rehydration solution, which is specifically formulated for this purpose.
Correct Answer is A
Explanation
A. Acute glomerulonephritis is characterized by the sudden onset of hematuria (reddish-brown urine), proteinuria (4+ protein), and a recent history of streptococcal infection, making it the most likely diagnosis.
B. Renal agenesis is a congenital condition and would not present suddenly with abdominal pain and hematuria.
C. Nephrotic syndrome typically presents with significant proteinuria, but the acute onset of symptoms and recent strep throat history point more toward glomerulonephritis.
D. Polycystic kidney disease usually presents with abdominal or flank pain, hypertension, and hematuria over a more chronic course, not typically after an acute infection.
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