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. Polyuria. Increased urination is not a common adverse effect of clozapine and does not require immediate reporting.
B. Fever. Clozapine can cause agranulocytosis, a serious condition that suppresses white blood cell production. Fever may indicate infection, which requires immediate evaluation.
C. Diarrhea. Gastrointestinal symptoms can occur with clozapine but are not typically urgent unless severe or persistent.
D. Diaphoresis. Excessive sweating is a possible side effect but does not require immediate medical attention.
Correct Answer is B
Explanation
A. Obtain a tympanogram reading prior to initiating the test. This is incorrect because a tympanogram assesses middle ear function and is not part of the Weber test, which evaluates hearing loss type.
B. Place a vibrating tuning fork on the top of the child's head. This is correct because the Weber test involves placing a vibrating tuning fork on the midline of the skull to determine if sound is heard equally in both ears, helping to differentiate between conductive and sensorineural hearing loss.
C. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears. This is incorrect because this describes the Rinne test, which compares air conduction to bone conduction.
D. Measure the amount of time the child can hear the sound. This is incorrect because the Weber test does not measure duration but assesses lateralization of sound perception.
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