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 B
Explanation
Choice A rationale:
Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped mass in the upper abdomen, and signs of dehydration.
Choice B rationale:
A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting. The infant may appear hungry after vomiting and will continue to feed, leading to weight loss.
Choice C rationale:
Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible peristalsis occurs as the infant tries to force the stomach contents through the narrowed pyloric sphincter. Weight loss is a result of poor feeding and vomiting.
Choice D rationale:
Distention of the lower abdomen and constipation are not typical findings in pyloric stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis primarily affects the upper gastrointestinal tract.
Correct Answer is A
Explanation
Choice A rationale
Activated charcoal is often used in cases of drug overdose or poisoning, including aspirin ingestion. It works by binding to the drug or toxin in the stomach, preventing it from being absorbed into the body. This makes activated charcoal an effective treatment for aspirin overdose in a toddler.
Choice B rationale
A chelating agent is a substance that can bind to heavy metals in the body, helping to remove them. While useful in cases of heavy metal poisoning, it would not be the first choice for an aspirin overdose.
Choice C rationale
Acetylcysteine is an antidote for acetaminophen (Tylenol) overdose, not aspirin. It works by replenishing glutathione, a substance that helps to detoxify the liver.
Choice D rationale
Digoxin immune FAB is used to treat digoxin toxicity. Digoxin is a medication used to treat heart conditions, and it is not related to aspirin.
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