Exhibits
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}
Rationale for Correct Choices:
- Seizures: The adolescent’s fever, headache, photophobia, and neck stiffness (resistance to flexion) are consistent with signs of meningitis, which can lead to seizures, especially in the setting of increased intracranial pressure. Seizures are a known complication of untreated or severe meningitis.
- Signs of meningeal irritation: The adolescent demonstrates classic signs of meningeal irritation, such as photophobia, severe headache, and neck stiffness, which suggest inflammation of the meninges. This is a key indicator of potential meningitis and the associated risk of seizures.
Rationale for Incorrect Choices:
- Lyme disease: While Lyme disease can cause neurological symptoms, including headache and fever, the absence of a characteristic erythema migrans rash or recent tick exposure makes it less likely.
- Constipation: Constipation is not a likely complication given the adolescent's current symptoms, which are focused on fever, headache, and neurological signs. It does not explain the risk for seizures.
- Mononucleosis: Although mononucleosis can cause fever and malaise, it typically does not present with neck stiffness, photophobia, or the acute onset of severe headache that is suggestive of meningitis. The symptoms in this case are more concerning for meningitis.
- Pneumonia: Pneumonia is unlikely given the absence of respiratory findings such as cough or difficulty breathing. The symptoms are more consistent with a central nervous system infection, like meningitis, than a respiratory infection.
- Fever: While fever is present in meningitis, it alone does not indicate the risk for seizures. It is the combination of fever, headache, photophobia, and meningeal signs that increases the risk for complications like seizures.
- Inability to eat and drink: The inability to eat and drink is likely a result of nausea and vomiting, which is common in many illnesses, including meningitis. However, it is not a direct indicator of the risk for seizures, which is more strongly linked to meningeal irritation.
- Respiratory findings: There are no significant respiratory symptoms, such as difficulty breathing or abnormal lung sounds, making respiratory findings irrelevant in this case. The adolescent’s symptoms are primarily neurological.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer two puffs of albuterol: Albuterol is a bronchodilator used as a quick-relief (rescue) medication for asthma attacks. It helps to open the airways and alleviate difficulty breathing. The nurse should administer albuterol as directed to help relieve the child’s symptoms.
B. Instruct the child to perform controlled breathing exercises: While controlled breathing exercises can be helpful for managing asthma, they are not the first action during an acute asthma attack. The priority is to use a quick-relief medication like albuterol.
C. Place the child in the supine position: Placing the child in the supine (lying flat) position could worsen breathing difficulty. The child should be placed in an upright position to help facilitate better airflow and reduce breathing distress during an asthma attack.
D. Encourage the use of a flutter mucus clearance device: A flutter mucus clearance device is used to help clear mucus in the lungs, but it is not appropriate for managing acute asthma symptoms. The priority is to administer a bronchodilator to relieve airway constriction.
Correct Answer is D
Explanation
A. "You should position the car seat at a 30-degree angle." The correct angle for rear-facing car seats is 45 degrees. A 30-degree angle may cause the infant’s head to fall forward, increasing the risk of airway obstruction.
B. "You should place a folded blanket to pad the back of the infant's head." Extra padding behind or around the infant's head is not recommended as it may interfere with the seat’s effectiveness and safety in a crash.
C. "You should use a car seat with a four-point harness." The recommended harness system is a five-point harness, which provides more secure restraint at the shoulders, hips, and between the legs.
D. "You should place the retainer clip at the level of the infant's armpits." Correct placement of the retainer (chest) clip is at armpit level. This ensures that the harness straps stay positioned over the shoulders, reducing the risk of injury during a crash.
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