Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?
A. Measure head circumference every shift
While monitoring for increased intracranial pressure is important, measuring headcircumference every shift may not be necessary unless there is a specific indication or change in the child's condition.
B. Admit the client to a private room
Admitting the child to a private room is necessary to reduce the risk of spreading the infection to others.
C. Place the client in a semi-Fowler's position
Placing the child in a semi-Fowler's position can help reduce intracranial pressure and promote comfort.
D. Implement seizure precautions
Implementing seizure precautions is important, as children with bacterial meningitis are at risk for seizures.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Paediatric Final Proctored Exam 2. Take the full exam now
Full Explanation
A. While monitoring for increased intracranial pressure is important, measuring head circumference every shift may not be necessary unless there is a specific indication or change in the child's condition.
B. Admitting the child to a private room is necessary to reduce the risk of spreading the infection to others.
C. Placing the child in a semi-Fowler's position can help reduce intracranial pressure and promote comfort.
D. Implementing seizure precautions is important, as children with bacterial meningitis are at risk for seizures.
Similar Questions
A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first?
A. Place the child on droplet precautions.
Placing the child on droplet precautions is the first priority to prevent the potential spread of infection, as epiglottitis is often caused by bacterial infection.
B. Assist with obtaining an x-ray of the child's neck.
While obtaining an x-ray may be part of the diagnostic process, the immediate concern is to prevent the spread of infection.
C. Administer 0.9% sodium chloride IV solution.
Administering IV fluids may be necessary, but placing the child on droplet precautions takes precedence.
D. Initiate IV antibiotics
Initiating IV antibiotics is an essential treatment for epiglottitis, but placing the child on droplet precautions is the initial step to prevent transmission to healthcare providers and other patients.
Full Explanation
A. Placing the child on droplet precautions is the first priority to prevent the potential spread of infection, as epiglottitis is often caused by bacterial infection.
B. While obtaining an x-ray may be part of the diagnostic process, the immediate concern is to prevent the spread of infection.
C. Administering IV fluids may be necessary, but placing the child on droplet precautions takes precedence.
D. Initiating IV antibiotics is an essential treatment for epiglottitis, but placing the child on droplet precautions is the initial step to prevent transmission to healthcare providers and other patients.
A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?
A. Ignore the temper tantrums.
Ignoring temper tantrums may not be effective in all situations. Some toddlers may escalate their behavior if they feel ignored.
B. Tell the child that temper tantrums are not acceptable.
Explicitly telling the child that temper tantrums are not acceptable may not be as effective in managing the behavior. Toddlers may not fully understand or respond well to verbal reasoning.
C. Distract the child by offering to play a game.
Distracting the child with a different activity, such as playing a game, can redirect their attention and help diffuse the situation.
D. Restrain the child physically.
Physical restraint is not an appropriate or effective method for managing temper tantrums. It can lead to increased resistance and may cause harm to the child.
Full Explanation
A. Ignoring temper tantrums may not be effective in all situations. Some toddlers may escalate their behavior if they feel ignored.
B. Explicitly telling the child that temper tantrums are not acceptable may not be as effective in managing the behavior. Toddlers may not fully understand or respond well to verbal reasoning.
C. Distracting the child with a different activity, such as playing a game, can redirect their attention and help diffuse the situation.
D. Physical restraint is not an appropriate or effective method for managing temper tantrums. It can lead to increased resistance and may cause harm to the child.
A child is admitted with a suspected diagnosis of Wilms’ tumor. The nurse should place a sign with which of the following warnings over the child’s bed?
A. Collect all urine.
Collecting all urine may be a part of the diagnostic process, but it is not the primary warning associated with Wilms' tumor.
B. Contact precautions.
Contact precautions are not typically required for Wilms' tumor.
C. Do not palpate abdomen.
The warning "Do not palpate abdomen" is crucial because palpation can potentially disrupt the tumor and cause hemorrhage.
D. No venipuncture or blood pressure in left arm.
No venipuncture or blood pressure in the left arm is not a typical precaution associated with Wilms' tumor. The emphasis is on avoiding abdominal palpation to prevent trauma to the tumor.
Full Explanation
A. Collecting all urine may be a part of the diagnostic process, but it is not the primary warning associated with Wilms' tumor.
B. Contact precautions are not typically required for Wilms' tumor.
C. The warning "Do not palpate abdomen" is crucial because palpation can potentially disrupt the tumor and cause hemorrhage.
D. No venipuncture or blood pressure in the left arm is not a typical precaution associated with Wilms' tumor. The emphasis is on avoiding abdominal palpation to prevent trauma to the tumor.