Normal total iron-binding capacity TIBC. The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take? The nurse should help the mother restrain the child to prevent him from injuring himself.
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The nurse should call the operator to page for seizure assistance. The nurse should clear the area and position the client safely. At the community center, the nurse leads an adolescent health information group, which often expands into other areas of discussion.
According to Erikson, this stage is known as:. The nurse is assessing a 9-month-old boy for a well-baby check up. Which of the following observations would be of most concern? The mother has not given him finger foods. The child does not sit unsupported.
The baby cries whenever the mother goes out. The nurse correctly replies that, according to the Denver Developmental Screen, the median age for walking is:. Sunshine, age 13, has had a lumbar puncture to examine the CSF to determine if bacterial infection exists. The best position to keep her in after the procedure is:. Prone for two hours to prevent aspiration , should she vomit. Supine for several hours, to prevent a headache. On her right sides to encourage return of CSF.
It is important to check circulation- sensation-movement:. The side effects of these drugs that you need to monitor this patient for include:. The adolescent patient has symptoms of meningitis : nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test:. The twelve-year-old boy has fractured his arm because of a fall from his bike.
After the injury has been casted, the nurse knows it is most important to perform all of the following assessments on the area distal to the injury except:. A recent episode of pharyngitis is the most important factor in establishing the diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack interest in food, these findings are not specific to rheumatic fever.
In an emergency, intraosseous drug administration is typically used when a child is critically ill and under age 3.
Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the doctor promptly of this finding. An open fontanel does not indicate abuse and is not associated with Tay-Sachs disease. A negative nitrogen balance may result from inadequate protein intake and is best detected by measuring the total protein level.
According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers and strives to attain a personal identity by becoming more independent from the family. Preschool-age children are most likely to view illness as a punishment for misdeeds. Option A: Separation anxiety , although seen in all age group, is most common in older infants.
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The other options ask for subjective replies that would be open to interpretation. The nurse should gather the other data later. Answer: D. The stress of starting nursery school may trigger a return to a level of successful behavior from earlier stages of development. The other options are more appropriate questions to ask when assessing vision in a geriatric patient. Rice cereal is the first solid food an infant should receive because it is easy to digest and is associated with few allergies.
Next, the infant can receive pureed fruits, such as bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt, and finally, meat. Succinylcholine is an ultra-short-acting depolarizing agent used for rapid-sequence intubation. Bradycardia can occur, especially in children. Atropine is the drug of choice in treating succinylcholine-induced bradycardia.
Because adolescents absorb less information through reading, providing age-appropriate reading materials is the least effective way to teach parenting skills to an adolescent. Normally the top of the ear aligns with an imaginary line drawn across the inner and outer canthus of the eye. Ears set below this line are associated with renal anomalies or mental retardation.
At age 3, gross motor development and refinement in eye-hand coordination enable a child to ride a tricycle. In a child, Eustachian tubes are short and lie in a horizontal plane, promoting entry of nasopharyngeal secretions into the tubes and thus setting the stage for otitis media. Increased urine output, a sign of improving kidney function, typically is the first sign that a child with acute post streptococcal glomerulonephritis APSGN is improving.
The primary purpose of administering corticosteroids to a child with nephritic syndrome is to decrease proteinuria.
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In an infant, signs of fluid volume deficit dehydration include sunken fontanels , increased pulse rate, and decreased blood pressure. They occur when the body can no longer maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to minimize fluid loss, which results in concentrated urine with a high specific gravity. Answer: C. By shaking it so that all the drug particles are dispersed uniformly. According to the American Association on Mental Deficiency, a person with an intelligence quotient IQ between 50 and 70 is classified as mildly mentally retarded but educable.
SIDS can occur any time between 1 week and 1 year of age. The incidence peaks at 2 to 4 months of age. An adolescent who demonstrates a preoccupation with death such as by talking about death frequently should be considered at high risk for suicide. Answer: B. Observing the child for 10 minutes to note for signs of anaphylaxis.
When administering chemotherapy , the nurse should observe for an anaphylactic reaction for 20 minutes and stop the medication if one is suspected. Chemotherapy is associated with both general and specific adverse effects, therefore close monitoring for them is important. When examining a toddler or any small child, the best way to perform the exam is from least to most intrusive.
The child with congenital heart disease develops polycythemia resulting from an inadequate mechanism to compensate for decreased oxygen saturation. Therefore, the mother should be advised not to give snacks to the child. Answer: A. Lead poisoning may be caused by inhalation of dust and smoke from leaded gas.
It may also be caused by lead-based paint, soil, water especially from plumbings of old houses. Glucosephosphate dehydrogenase deficiency G6PD is an X-linked recessive hereditary disease characterised by abnormally low levels of glucosephosphate dehydrogenase abbreviated G6PD or G6PDH , a metabolic enzyme involved in the pentose phosphate pathway, especially important in red blood cell metabolism.
For the child with iron deficiency anemia , the blood study results most likely would reveal decreased mean corpuscular volume MCV which demonstrates microcytic anemia, decreased hemoglobin, decreased hematocrit and elevated total iron binding capacity.
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The primary role of the nurse when a patient has a seizure is to protect the patient from harming him or herself. The patient can lose vascular status without the nurse being aware if left for more than 4 hours, yet checks should not be so frequent that the patient becomes anxious. Vital signs are generally checked q4h, at which time the CSM checks can easily be performed. Bronchodilators can produce the side effects listed in answer choice A for a short time after the patient begins using them.
Meningitis is an infection of the meninges, the outer membrane of the brain.
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Since it is surrounded by cerebrospinal fluid , a lumbar puncture will help to identify the organism involved. Capillary refill, pulses, and skin temperature and color are indicative of intact circulation and absence of compartment syndrome. Skin integrity is less important. Save my name, email, and website in this browser for the next time I comment. Notify me of follow-up comments by email. Notify me of new posts by email. Since we started in , Nurseslabs has been visited over million times as of and has become one of the most trusted nursing websites helping thousands of aspiring nurses achieve their goals.
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