A family brought their 3-week-old infant to the hospital by ambulance after having a seizure at home.
The baby received phenytoin in the ambulance and arrived at the hospital on 1 L/minute oxygen with a 22-gauge peripheral IV line in the left saphenous vein.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
Review H and P, nurse’s notes, flow sheet, and orders.
Call for a chest x-ray.
Hypocalcemia.
Monitor respiratory rate.
The Correct Answer is C
Choice A rationale
Reviewing the history and physical (H&P), nurse’s notes, flow sheet, and orders is a standard part of nursing care for any patient. However, in the case of a 3-week-old infant who has had a seizure, this action alone would not directly address the condition the infant is most likely experiencing.
Choice B rationale
While calling for a chest x-ray could be part of the diagnostic process for certain conditions, it is not typically the first action taken in response to a seizure in an infant.
Choice C rationale
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.
Choice D rationale
Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure. However, it does not specify the condition the infant is most likely experiencing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1: Convert the client’s weight from pounds to kg. 1 kg is approximately 2.2 lbs. So, 176 lbs
÷ 2.2 = 80 kg (rounded to the nearest whole number).
Step 2: Calculate the total mg of enoxaparin sodium needed per day. The prescription is for 1.5 mg/kg/day. So, 80 kg × 1.5 mg/kg/day = 120 mg/day.
Step 3: Calculate the mL of enoxaparin sodium needed. The medication is available in a 120 mg/0.8 mL prefilled syringe. So, 120 mg ÷ 120 mg/0.8 mL = 0.8 mL. The nurse should administer 0.8 mL.
Correct Answer is C,A,B,D
Explanation
Step 1: Complete a focused assessment. The first step in managing a patient with abdominal pain and distention, vomiting, and constipation is to perform a focused assessment. This includes assessing the patient’s vital signs, pain level, abdominal distention, bowel sounds, and any other relevant physical findings.
Step 2: Elevate the head of the bed. Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has recently vomited.
Step 3: Send the emesis sample to the lab. Analyzing the vomitus can provide important information about the possible causes of the patient’s symptoms. For example, the presence of blood could suggest a gastrointestinal bleed.
Step 4: Offer PRN pain medication. After the initial assessment and interventions, the nurse should address the patient’s comfort. Pain management is an important part of patient care, but in this scenario, it is not the highest priority.
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