A nurse is assisting with collecting data from a 10-month-old in the emergency department.
Medical History: Guardians brought the infant to the emergency room after witnessing the infant’s arms and legs shaking.
The infant did not respond to the guardians’ voices during that time.
The episode lasted approximately 5 min and the infant was sleeping soundly afterwards.
On the way to the emergency department, the infant had another episode of shaking of the extremities and drooling. The infant was asleep when they arrived for evaluation.
The infant has no prior medical or surgical history.
Born full-term at 40 weeks to a birth mother who had regular prenatal visits.
Actions to Take: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress.
Potential Condition
Parameters to Monitor 1
Parameters to Monitor 2
Vitamin
Blood pressure
The Correct Answer is A
The correct answer is A. Potential Condition.
The infant’s symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant’s neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Mucus and blood in stools, often described as “currant jelly” stools, are a common symptom of intussusception.
Choice B rationale
Increased appetite is not typically associated with intussusception. In fact, children with this condition may experience decreased appetite due to abdominal pain.
Choice C rationale
Jaundice is not a symptom of intussusception. Jaundice, a yellowing of the skin and eyes, is more commonly associated with liver conditions.
Choice D rationale
Drooling is not a typical symptom of intussusception. Symptoms of intussusception are primarily gastrointestinal, including abdominal pain and bloody stools.
Correct Answer is A
Explanation
Choice A rationale
Bending forward from the waist with the head and arms downward, also known as the Adams forward bend test, is the standard screening test for scoliosis.
Choice B rationale
Touching the chin to the chest and then looking up at the ceiling does not provide a view of the spine necessary for scoliosis screening.
Choice C rationale
Lying prone on the examination table is not a standard position for scoliosis screening.
Choice D rationale
Turning to the side and remaining in a relaxed position is not a standard position for scoliosis screening.
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