During an episode of status epilepticus of a hospitalized child, what is the priority intervention?

Administering anti-seizure medication

Restraining the child to prevent injury

Providing emotional support to the child's family

Documenting the seizure activity

Answer and Explanation

The Correct Answer is A

A. Administering anti-seizure medication is the priority. In a child experiencing status epilepticus, immediate administration of anti-seizure medication is essential to stop the seizure activity and prevent further neurological damage. The primary goal is to terminate the seizure as quickly as possible.

B. Restraining the child to prevent injury is not the priority. Restraining a child during a seizure can increase the risk of injury and is not recommended. Instead, protecting the child from harm by placing them in a safe position is more appropriate.

C. Providing emotional support to the child's family is important, but it is not the immediate priority during the acute phase of status epilepticus. The child's immediate safety and health take precedence.

D. Documenting the seizure activity should be done after ensuring that the seizure has been controlled. Accurate documentation is important, but it is secondary to the intervention needed to stop the seizure.

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Correct Answer is A

Explanation

A. Urine specific gravity 1.015 is correct. A specific gravity of 1.015 indicates good hydration status and that the child is effectively retaining fluids after oral rehydration therapy. Normal urine specific gravity ranges from 1.010 to 1.020.

B. Respiratory rate 24/min is not directly related to hydration status and does not necessarily indicate that rehydration therapy has been effective. It is a normal rate for a 3-year-old child, but respiratory rate alone isn't an indicator of fluid balance.

C. Heart rate 130/min is elevated for a 3-year-old child and may indicate dehydration or other stressors, suggesting that oral rehydration therapy has not been completely effective. A normal heart rate for this age is typically 80-120 beats per minute.

D. Capillary refill greater than 3 seconds is a sign of dehydration and poor perfusion, indicating that the oral rehydration therapy has not been effective in restoring hydration. Normal capillary refill time is less than 2 seconds.

A. An elevated red blood cell count B. A decreased white cell count C. An elevated white blood cell count D. A normal glucose

Correct Answer is C

Explanation

A. An elevated red blood cell count is not a typical finding in bacterial meningitis. An increase in red blood cells in cerebrospinal fluid (CSF) is more indicative of a traumatic lumbar puncture or hemorrhage.

B. A decreased white cell count would not be expected in bacterial meningitis. Bacterial infections typically lead to an increase in white blood cell count as part of the immune response to fight the infection.

C. An elevated white blood cell count is a hallmark of bacterial meningitis. This finding indicates an immune response in the CSF to the presence of bacteria. The cells are primarily neutrophils in bacterial infections.

D. A normal glucose level is not expected in bacterial meningitis. Glucose is typically decreased due to the consumption of glucose by bacteria and white blood cells in the CSF.

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During an episode of status epilepticus of a hospitalized child, what is the priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective?

Correct Answer is A

Explanation

A lumbar puncture is done on an infant suspected to have meningitis. If the infant has bacterial meningitis, the nurse would expect the cerebral spinal fluid to show what result?

Correct Answer is C

Explanation

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