4/21 Flashcards
A 3-year-old child is brought to the emergency department with febrile seizure. Which of the following is the priority nursing interventions?
A. check the child’s airway and breathing
B. administer antipyretics
C. initiate seizure precautions
D. administer an antiepileptic medication
Answer: A
Which of the following manifestations would lead the nurse developmental dysplasia of the hip? SATA
A. Stepping reflex
B. Positive Ortolani sign
C. positive Kernig sign
D. clicking when leg is rotated out
E. uneven gluteal folds
Answer: B, D, E
Rationale: Kernig sign - meningitis
Ortolani - barlow after
The nurse identifies that a priority nursing diagnosis for a child with a newlybroken femur is “injury risk for peripheral neurovascular compromise.” implementation of which nursing intervention will reduce this risk?
A. initiate hourly assessment of the child’s foot distal to the fracture site
B. perform hourly assessments of the child’s level of consciousness
C. assign an UAP to measure the child’s vitals hourly
D. evaluate the child for orthostatic hypotension
Answer: A
An infant is diagnosed with bacterial meningitis. Which of the following is a priority nursing action?
A. keeping the infant in a supine position
B. encouraging the infant to drink fluids
C. administering oral antibiotics
D. isolating the infant from other infants
Answer: D
Which clinical manifestation of increasing intracranial pressure (ICP) will the nurse expect to assess in the 3-year-old diagnosed with meningitis?
A. decreased respiratory rate
B. bulging fontantels
C. seizures
D. hyperactivity
E. difficulty with speech
Answer: A, C, E
Rationale: Typ pretty down and not hyperactive with increased ICP
An 8-year-old child sustained a fracture in the epiphyseal plate of her right femur when she fell out of a tree and landed on the edge of a picnic table. The nurse caring for her should consider which of the following?
A. this is an unusual fracture in young children
B. this type of fracture is inconsistent with a fall as reported
C. bone growth can be affected with this type of fracture
D. healing is usually delayed in this type of fracture
Answer: C
Rationale: Growth plate
