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 D
Explanation
Choice A rationale
Discouraging the client from ambulating is not the best action. While it’s important to limit weight-bearing activities initially, movement is encouraged to promote circulation and prevent complications such as deep vein thrombosis.
Choice B rationale
Using a hair dryer on a hot setting to dry the cast is not recommended. Heat can cause the cast to dry out and crack, and it can also burn the skin.
Choice C rationale
Keeping the client’s leg in a dependent position is not advisable. This can lead to increased swelling and pain, and potentially delay healing.
Choice D rationale
Performing a neurovascular check of the lower extremities is the correct action. This involves assessing for pain, pallor, pulselessness, paresthesia, and paralysis. These checks are crucial for monitoring for complications such as compartment syndrome and ensuring the cast is not too tight.
Correct Answer is D
Explanation
Choice A rationale
The incubation period for varicella, or chickenpox, is typically longer than 2 to 5 days. It usually ranges from 10 to 21 days.
Choice B rationale
An incubation period of 3 to 4 weeks is within the typical range for varicella. However, the average incubation period is usually around 14 to 16 days.
Choice C rationale
An incubation period of 7 to 10 days is shorter than the typical incubation period for varicella, which is usually around 14 to 16 days.
Choice D rationale
An incubation period of 2 to 3 weeks is within the typical range for varicella. The average incubation period is usually around 14 to 16 days.
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