A nurse is caring for a client who has suspected meningitis and a decreased level of consciousness.
Which of the following actions by the nurse is
... [Show More] appropriate?
A) Place the client on NPO status
B) Prepare the client for a liver biopsy
C) Position the client dorsal recumbent
D) Put the client in a protective environment - A
A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the
following findings should the nurse identify as viral meningitis? (Select all that apply).
A) Negative gram stain
B) Normal glucose content
C) Cloudy color
D) Decreased WBC count
E) Normal protein content - A, B, E
A nurse is caring for a 4-month-old infant who has meningitis. Which of the following findings is
associated with this diagnosis?
A) Depressed anterior fontanel
B) Constipation
C) Presence of the rooting reflex
D) High-pitched cry - D
A nurse is caring for a school-age client who possibly has Reye syndrome. Which of the following is a risk
factor for developing Reye syndrome?
A) Recent history of infectious cystitis caused by Candida
B) Recent history of bacterial otitis media
C) Recent episode of gastroenteritis
D) Recent episode of Haemophilus influenzae meningitis - C
A nurse is developing an in-service about viral and bacterial meningitis. The nurse should include that
the introduction of which of the following immunizations decreased the incidence of bacterial
meningitis in children? (Select that apply.)
A) Inactivated polio vaccine (IPV)
B) Pneumoccocal conjugate vaccine (PCV)
C) Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP)
D) Haemophilus influenzae type B (Hib) vaccine
E) Trivalent inactivated influenza vaccine (TIV) - B, D
A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse
expect? (Select all that apply.)
A) Loss of consciousness
B) Appearance of daydreaming
C) Dropping held objects
D) Falling to the floor
E) Having a piercing cry - A, B, C
A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the
priority action for the nurse to take?
A) Maintain the child in a side-lying position
B) Loosen the child's restrictive clothing
C) Reorient the child to the environment
D) Note the time and characteristics of the child's seizure - A
A nurse is providing teaching to the parent of a child who is to have an EEG. Which of the following
responses should the nurse include in the teaching?
A) "Decaffeinated beverages should be offered on the morning of the procedure"
B) "Do not wash your child's hair the night before the procedure"
C) "Withhold all foods the morning of the procedure"
D) "Give your child an analgesic the night before the procedure" - A
A nurse is teaching a group of parents about the risk factors for seizures. Which of the following factors
should the nurse include in the teaching? (Select all that apply.)
A) Febrile episodes
B) Hypoglycemia
C) Sodium imbalances
D) Low serum lead levels
E) Presence of diphtheria - A, B, C
A nurse is reviewing treatment options with the parent of a child who has worsening seizures. Which of
the following treatment options should the nurse include in the discussion? (Select all that apply.)
A) Vagal nerve stimulator
B) Additional anti-epileptic medications
C) Corpus callosotomy
D) Focal resection
E) Radiation therapy - A, B, C, D
A nurse is in the emergency department assessing a child following a motor-vehicle crash. The child is
unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is
bleeding. Which of the following actions should the nurse take first?
A) Stabilize the child's neck
B) Clean the child's laceration with soap and water
C) Implement seizure precautions for the child
D) Initiate IV access for the child - A
A nurse is caring for an adolescent who has a closed head injury. Which of the following findings are
indications of increased intracranial pressure (ICP)? (Select all that apply.)
A) Report of headache
B) Alteration in pupillary response
C) Increased motor response
D) Increased sleeping
E) Increased sensory response - A, B, D
A nurse is caring for a child who has increased ICP. Which of the following actions should the nurse take?
(Select all that apply.)
A) Suction the ET tube every 2 hours
B) Maintain a quiet environment
C) Use two pillows to elevate the head
D) Administer a stool softener
E) Maintain body alignment - B, D, E
A nurse is caring for a child who is taking mannitol for cerebral edema. Which of the following adverse
effects should the nurse monitor the child for and report to the provider?
A) Bradycardia
B) Weight loss
C) Confusion
D) Constipation - C
A nurse is planning to perform a peripheral vision test on a child. Which of the following actions should
the nurse take?
A) Place the child 10 feet away from a Snellen chart
B) Show a set of cards to the child one at a time
C) Cover the child's eye while performing the test on the other eye
D) Have the child focus on an object while performing the test - D
A nurse is teaching a group of parents about possible manifestations of Down syndrome. Which of the
following findings should the nurse include in the teaching? (Select all that apply.)
A) A large head with bulging fontanels
B) Larger ears that are set back
C) Protruding abdomen
D) Broad, short feet and hands
E) Hypotonia - C, D, E
A nurse is assessing a child who has myopia. Which of the following findings should the nurse expect?
(Select all that apply.)
A) Headaches
B) Photophobia
C) Difficulty reading
D) Difficulty focusing on close objects
E) Poor school performance - A, C, E
A nurse is assessing a toddler for possible hearing loss. Which of the following findings are indications of
a hearing impairment? (Select all that apply.)
A) Uses monotone speech
B) Speaks loudly
C) Repeats sentences
D) Appears shy
E) Is overly attentive to the surroundings - A, B, D [Show Less]