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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Stating that the client received morphine "around lunch" is too vague. The exact time, dose, and effect should be included for accurate pain management.
B. A lung biopsy is a significant procedure that requires close monitoring for complications such as pneumothorax or bleeding. The oncoming nurse must be aware to provide appropriate post-procedure care.
C. General information about vital signs being taken every 4 hours is routine and not critical for handoff unless there are abnormalities or changes.
D. The presence of the client’s partner is not essential clinical information unless it impacts care, such as decision-making or emotional support needs.
Correct Answer is C
Explanation
A. Rotavirus vaccine is for infants, not older adults. It is given to prevent severe diarrhea caused by rotavirus.
B. Human papillomavirus (HPV) vaccine is recommended for adolescents and young adults, typically before age 26, to prevent cervical and other cancers.
C. Herpes zoster (shingles) vaccine is recommended for older adults, usually starting at age 50 or 60, to reduce the risk of shingles and its complications.
D. DTaP is given to infants and young children. Instead, older adults should receive a Td or Tdap booster every 10 years.
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