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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. The guardian wants to accompany the child from the ED to the radiology department. This is a typical parental response and does not indicate maltreatment. Parents often want to stay with their child for reassurance.
B. The guardian states the child fell off the swing in the backyard. This is a plausible explanation for an injury in a preschooler, though the consistency of the story with the injury should still be assessed.
C. The child was brought to the ED 2 days after the injury occurred. A delay in seeking medical care for a significant injury is a potential warning sign of child maltreatment and warrants further investigation.
D. The child cries loudly when their arm is moved or manipulated. Pain with movement is expected with a fracture and does not indicate maltreatment.

A. Insert an NG tube for a client who requires enteral feedings. B. Record a client's intake after each meal. C. Obtain a client's vital signs every 4 hr. D. Instruct a client on the use of an incentive spirometer. E. Transfer a client to physical therapy.

Correct Answer is ["B","C","E"]

Explanation

A. Insert an NG tube for a client who requires enteral feedings. This is incorrect because inserting an NG tube requires assessment and skill beyond the scope of practice of assistive personnel. This task should be performed by a nurse.
B. Record a client's intake after each meal. This is correct because recording intake is a non-clinical task within the scope of an assistive personnel’s role.
C. Obtain a client's vital signs every 4 hr. This is correct because measuring and documenting vital signs is a standard duty that assistive personnel can perform.
D. Instruct a client on the use of an incentive spirometer. This is incorrect because client education is a nursing responsibility and cannot be delegated to assistive personnel.
E. Transfer a client to physical therapy. This is correct because assistive personnel can safely assist with client transfers as long as no clinical judgment is required.

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A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department (ED) is assessing a preschooler who has a fractured arm. For which of the following should the nurse further investigate as a warning sign of child maltreatment?

Correct Answer is C

Explanation

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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