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.
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Related Questions
Correct Answer is D
Explanation
A. Encouraging handwashing is important to prevent spreading infection and shows understanding of hygiene practices.
B. Advising the child not to touch their face is important to prevent secondary infections and spread of the rash.
C. Providing a separate towel helps prevent the spread of infection, demonstrating good understanding of precautions.
D. Filling a prescription for antiviral ointment is inappropriate in this case; the honey-crusted plaques suggest impetigo, which is typically treated with topical or oral antibiotics, not antiviral ointment.
Correct Answer is ["A","B","D"]
Explanation
A. Providing written information about the medication is important for ensuring the parents understand the treatment plan and can reference it later.
B. Discussing the potential adverse effects of the medication prepares the parents for what to monitor in their child and when to seek help.
C. Stopping the medication when the child feels better is incorrect, as it is essential to complete the full course of antibiotics to prevent resistance and recurrence of infection.
D. Explaining the reason why the child is taking the medication helps parents understand its importance and can enhance adherence to the treatment plan.
E. Advising against using a kitchen spoon for administering the medication is important, as it can lead to incorrect dosing; proper dosing devices should be used instead.
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