A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect?

A. Spina bifida.

Explanation: Correct Choice. Spina bifida is a neural tube defect (NTD) that occurs during early fetal development when the neural tube doesn't close completely. It can result in various degrees of spinal cord and nerve damage. This is a suitable example to include when teaching about neural tube defects.

B. Hydrocephalus.

Explanation: Hydrocephalus is not a neural tube defect itself. It's a condition characterized by the accumulation of cerebrospinal fluid in the brain, leading to increased intracranial pressure. It can be caused by various factors, but it's not directly related to neural tube development.

C. Cerebral palsy.

Explanation: Cerebral palsy is a group of motor disorders caused by damage to the developing brain, usually before birth. It is not a neural tube defect. Instead, it's related to brain injury or abnormal development.

D. Muscular dystrophy.

Explanation: Muscular dystrophy is a group of genetic disorders characterized by progressive muscle weakness and degeneration. It's not related to neural tube defects. Muscular dystrophy affects muscle tissue, while neural tube defects involve improper development of the neural tube.

A) Place a tongue depressor in the client's mouth:

Incorrect. Placing a tongue depressor in the client's mouth is not recommended during a seizure. Doing so can lead to injury, as the child may bite down on the depressor and cause harm to their teeth or mouth.

B) Restrain the client:

Incorrect. Restraining a person during a seizure can be extremely dangerous. It can lead to physical harm to both the person experiencing the seizure and the person trying to restrain them. Restraining can increase the risk of fractures, dislocations, and other injuries.

C) Assess the client's airway patency:

Correct. Assessing the client's airway patency is essential during a seizure. The nurse should ensure that the child's airway is clear and open to maintain proper breathing. This involves observing for any obstruction or difficulty in breathing and taking appropriate measures to keep the airway open.

D) Remove objects from the client's bed:

Correct. Removing objects from the client's bed is a necessary action to prevent injury during a seizure. Objects on the bed can pose a risk of harm to the child if they were to strike them during the seizure. Creating a safe environment by removing potential hazards is important.

E) Place the client in a side-lying position:

Correct. Placing the client in a side-lying position is recommended during a seizure. This position helps prevent aspiration and maintains a clear airway. It also reduces the risk of choking and allows any fluids to drain from the mouth, minimizing the risk of choking.

In summary:

Choice A is incorrect because placing a tongue depressor can cause injury.

Choice B is incorrect because restraining can lead to harm.

Choice C is correct because assessing the airway ensures proper breathing.

Choice D is correct because removing objects reduces the risk of injury.

Choice E is correct because placing the client in a side-lying position helps maintain a clear airway and prevents aspiration.