A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?
An infant who has respiratory syncytial virus
A child who has bacterial meningitis
An infant who has hypertrophic pyloric stenosis
A child who has Kawasaki disease
The Correct Answer is B
A. An infant who has respiratory syncytial virus (RSV) primarily experiences respiratory symptoms such as wheezing, coughing, and difficulty breathing. RSV does not typically cause seizures.
B. A child who has bacterial meningitis is at high risk for seizures due to increased intracranial pressure, cerebral irritation, and inflammation. Seizure precautions, including padded side rails, oxygen, and suction at the bedside, should be initiated.
C. An infant who has hypertrophic pyloric stenosis experiences projectile vomiting and dehydration but is not at risk for seizures.
D. A child who has Kawasaki disease is at risk for coronary artery complications, but seizures are not a common complication of this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wire cutters. This is incorrect because wire cutters are used for clients with wired jaws in case of an emergency but are not needed for chest tube management.
B. Padded clamp. This is correct because a padded clamp is necessary in case the chest tube needs to be momentarily clamped for troubleshooting air leaks or before removal.
C. Montgomery straps. This is incorrect because Montgomery straps are used to secure frequent dressing changes, such as for abdominal wounds, and are not relevant to chest tube management.
D. Tracheostomy tray. This is incorrect because a tracheostomy tray is used for clients at risk for airway obstruction, which is not a routine need following a thoracotomy with chest tube placement.
Correct Answer is C
Explanation
A. Yogurt and granola is not appropriate because granola is hard and can be difficult to swallow, increasing the risk of aspiration.
B. Wheat toast with butter is not appropriate because toast is dry and can be difficult to chew and swallow, posing a choking hazard.
C. Pancakes with syrup are soft and easy to chew, making them a suitable choice for a mechanically altered diet. The syrup adds moisture, further aiding swallowing.
D. Banana and nut muffin is not appropriate because muffins can be dry and crumbly, and nuts are a choking hazard for clients with dysphagia.
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