ATI Quiz 5 Practice Questions with Rationales

ATI Quiz 5 Practice Questions with Rationales 1. A nurse is collecting data from a 9-month-old infant. Which of the following findings would require further intervention? a. Positive Babinski reflex R The Babinski reflex disappears after 1 year of age. Therefore, a 9-month-old infant with a positive Babinski reflex is a finding that does not require further intervention. b. Positive Moro reflex R The Moro reflex disappears approximately at 3-4 months of age. Therefore, a 9- month-old infant with a positive Moro reflex is a finding that requires further intervention c. Negative Doll’s eye reflex R A negative Doll’s eye reflex is a normal finding. Therefore, a 9-month-old infant with a negative Doll’s eye reflex is a finding that does not require further intervention. d. Negative Crawl reflex R A negative Crawl reflex disappears after 6 months of age. Therefore, a 9-month-old infant with a negative Crawl reflex is a finding that does not require further intervention. 2. A nurse working in a pediatric clinic is collecting data on a preschool-age child who has a rash on his arm. The mother reports that the child was recently exposed to impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection? a. Scaling patches that are clear in the center. R This finding is associated with tinia corporis (ringworm), not impetigo. b. Honey-colored crusts caused by dried exudate. R This finding is associated with impetigo contagiosa. Honey-colored crusts develop when vesicles rupture and the exudate dries. c. Firm papules with a roughened, finely papillomatous texture. R This finding is associated with verruca (warts), not impetigo. d. Lines of small blisters surrounding one large blister. R This finding is associated with poison ivy, not impetigo. 3. A nurse is collecting data from an 11-month-old infant. Which of the following clinical manifestations is suggestive of a central nervous system infection? a. Oliguria R Oliguria is a clinical manifestation of shock or kidney disease. However, it is not a clinical manifestation of a central nervous system infection. b. Bulging fontanel R A central nervous system infection causes increased intracranial pressure. Therefore, bulging fontanels are a clinical manifestation of a central nervous system infection. c. Negative Brudzinski sign R A positive Brudzinski sign is a clinical manifestation of a central nervous system infection. d. Jaundice R Jaundice is a clinical manifestation of liver disease. However, not a clinical manifestation of a central nervous system infection. 4. A nurse is reinforcing teaching to an adolescent client regarding administration of Gardasil vaccine. For which of the following sexually transmitted infections does the vaccine provide immunity? a. Human papillomavirus (HPV) R Gardasil is the only HPV vaccine that helps provide immunity against 4 types of HPV. These include type 6, 11, 16, and 18. The immunization schedule for Gardasil is 3 injections over a 6 month period. Clients should receive this vaccine between the ages of 9 and 26. b. Herpes simplex virus (HSV-2) R Gardasil does not provide immunity against HSV-2. c. Chlamydia trachomatis R Gardasil does not provide immunity against chlamydia trachomatis. d. Gonorrhea R Gardasil does not provide immunity against gonorrhea. 5. A nurse is caring for a 4-year-old child who had hydrocephalus as an infant and is admitted with a malfunctioning ventriculoperitoneal shunt. Following new shunt placement, the nurse conducts a postoperative check. Which of the following findings requires immediate action by the nurse? a. Sleepy and very difficult to arouse R The child may be sleepy following surgery but should be easily aroused. Lethargy could indicate a decreased level of consciousness or increasing intracranial pressure and should be reported immediately. b. Lying flat on the unaffected side R The child should be positioned on the unaffected side to avoid pressure on the shunt valve. Lying flat is often prescribed after initial shunt placement, not necessarily after elective replacement. If the child has signs of increasing intracranial pressure, the provider might prescribe upright positioning. c. BP 100/60, apical pulse rate of 90 R These vital signs are within the expected range for a 4-year-old child. d. Urine output 50 mL in 2 hr R A urine output of 50 mL in 2 hr indicates adequate renal function for a 4-year-old child. 6. A nurse is caring for a toddler scheduled to have a lumbar puncture (LP) to rule out meningitis. The nurse who is planning to assist with the procedure should a. have another nurse to help hold the toddler. R One nurse should be able to assist with the procedure. b. sit the toddler on the side of bed. R This is not an appropriate position for a toddler who is being prepared for a lumbar puncture. c. place the toddler in a side-lying, knee-chest position. R A lumbar puncture (LP) is a procedure in which a small amount of the fluid that surrounds the brain and spinal cord called the cerebrospinal fluid, or CSF, is removed and examined. The client is positioned on the side in a fetal position (knees curled to abdomen and chin tucked to chest). d. use a mummy restraint. R Mummy restraints may be used when performing a procedure such as suturing a facial laceration, but it would place the child in an inappropriate position when performing an lumbar puncture. 7. A nurse is caring for a child who just underwent insertion of a ventriculoperitoneal shunt. Which of the following positions would be appropriate for the client? a. On the operative side R On the operative side is not an appropriate position for this client. b. A 45-degree head elevation R A 45-degree elevation of the head of bed is not the appropriate position for this client. c. Prone R Lying on the stomach is not the appropriate position for this client. d. Dorsal recumbent R Lying flat on the back is the appropriate position for this client. This position keeps the head level with the body, which reduces the risk of cerebrospinal fluid flowing too rapidly, leading to rapid decompression, which can result in tearing of the cerebral arteries. 8. A nurse is caring for a child who is having a seizure. Which of the following is an appropriate action by the nurse? (Select all that apply.) a. Check the client’s airway for patency. R Assess the client’s airway patency is correct. This is an appropriate action by the nurse. b. Place a tongue depressor in the client’s mouth. R Place a tongue depressor in the client’s mouth is incorrect. Placing something in the client’s mouth can cause injury, and is not an appropriate action by the nurse. c. Place the bed in a low position. R Place the bed in a low position is correct. This is an appropriate action by the nurse. d. Place the client in prone position. R Place the client in prone position is incorrect. The client should be positioned side- lying to prevent aspiration of secretions or vomit. e. Restrain the client. R Restrain the client is incorrect. Restraining the client can cause injury, and is not an appropriate action by the nurse. 9. A nurse is caring for a child with a suspected diagnosis of bacterial meningitis. Which of the following is the priority action by the nurse? a. Administer antibiotics when available. R The priority nursing action is to administer antibiotics when available. Bacterial meningitis is an acute inflammation of the meninges and the CNS, and antibiotic therapy has a marked effect on the course and prognosis of the illness. b. Reduce environmental stimuli. R Reducing environmental stimuli is an appropriate action by the nurse; however, this is not the priority. c. Document intake and output. R Documenting intake and output is an appropriate action by the nurse; however, this is not the priority. d. Maintain seizure precautions. R Maintaining seizure precautions is an appropriate action by the nurse; however, this is not the priority. 10. A nurse is instructing a mother on how to care for a child who has impetigo contagiosa. Which of the following should the nurse plan to include in her education of the mother? a. Isolate this child from others in his family. R The mother should know isolation precautions are not needed; however, limiting contact with others when the wound is weeping will prevent spread of the infection. b. Wash toys with soap and very hot water. R The mother should know to wash the toys with soap and hot water to disinfect and prevent the spread of the infection. c. Vaccinated the other family member for disease. R The mother should know there is no vaccination for the infection d. Implement no special precautions. R The mother should know to implement universal precautions to prevent the spread of the infection. 11. A school nurse identifies that a child has pediculosis capitis and educates the child's parent about the condition. Which of the following statements by the parent indicates an understanding of the teaching? a. "All recently worn clothing, bedding, and towels must be washed in hot water." R Pediculosis capitis is commonly referred to as head lice. All recently worn clothing, bed sheets, and towels need to be washed in hot water. Anything that cannot be washed should be sealed in a plastic bag for 10 to 14 days. This might include jackets, sweaters, hats, pillows, bicycle helmets, and stuffed animals that the child may sleep with. Furniture, carpets, and car seats can be sprayed with a variety of over-the-counter products. b. "My child must have a physician's note to return to school." R The school nurse will examine the child upon returning to determine if the child is free of infestation. c. "I will treat all the family members to be on the safe side." R Only family members who actually have lice should be treated because there are side effects with the treatment, known as pediculicides, as with any medication. d. "Toys that can't be dry cleaned or washed must be thrown out." R Items that can't be dry cleaned or washed can be closed up inside a plastic bag for 10 to 14 days. This might include jackets, sweaters, hats, pillows, bicycle helmets, and stuffed animals 12. A charge nurse, following hospital policy, reports an incident of suspected child abuse. The parent of the child becomes upset and demands to know the reason for the nurse's action. The appropriate nursing response to the parent should be which of the following? a. "As a nurse, I am required by law to report incidents of suspected child abuse." R A nurse is required by law to report suspected child abuse. Therefore, this is a truthful, non-accusatory response to the parent. b. "I am unable to discuss this, but you can talk to my supervisor." R The nurse does not need clarification by her supervisor to speak with the parent. c. "Perhaps you should leave before I call security." R The nurse should not ask the parent to leave in case permission is needed for surgery or a procedure. d. "I reported the incident to my supervisor who decided to contact the authorities." R The nurse supervisor does not decide to contact the authorities 13. A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this condition? a. Firmly attached white particles on the hair R Pediculus capitis, or head lice, are tiny parasitic insects that live on the scalp and can be spread by close contact with other people. Their eggs (nits) appear much like flakes of dandruff, but are stuck firmly to the hair shaft instead of flaking off of the scalp. Head lice can spread readily among school children. b. Itching and scratching of the head R There are many other causes of scalp itching, so this is not a definitive symptom of pediculosis. c. Patchy areas of hair loss R Alopecia, or patchy areas of hair loss, is a typical finding in ringworm, a superficial infection of the scalp by a fungus. d. Thick, yellow, crusted lesion on a red base R Thick, golden yellow, crusted lesions on a red base are a typical finding in impetigo, a superficial infection of the skin that may often involve the face or scalp. 14. A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? a. Dehydration R Dehydration is a complication that may occur as a result of a fever, however it is not considered a complication of the hypothermia blanket therapy. b. Seizures R Seizures are a complication associated with meningitis and should be monitored in this client; however, it is not considered a complication of the hypothermia blanket therapy. c. Burns R Burns are associated with the improper use of heating pads, not a hypothermia blanket. d. Shivering R The hypothermia blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption. 15. A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client? a. Trendelenburg R Positioning the child in Trendelenburg could result in inadequate functioning of the VP shunt due to the child's head being lower than the rest of his body. b. Semi-Fowler's R Positioning the child in semi-Fowler's could result in a rapid reduction of intracranial fluid. c. Prone R Positioning the child prone could result in inadequate functioning of the VP shunt due to the need to position the child's head to the side. d. On the unoperated side R The nurse should position the child flat on the unoperated side to prevent a rapid reduction of intracranial fluid and to protect the child for injuring the operative site. 16. A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take? a. Insert a tongue blade in the client's mouth. R The nurse should never force anything into the mouth of a client who is having a seizure. Doing so can obstruct the client's airway or chip the client's teeth. b. Place the client on his side. R The nurse should place the client on his side. This position drops the tongue to the side of the client's mouth and prevents the client's airway from being obstructed. c. Hold the client's arms and legs from moving. R The nurse should not try to restrain the client from moving because this could injure the client. d. Place the client back in bed. R The nurse should remove all furniture out of the way from the client during the seizure and place the client‘s head on a pillow or lap. However, the nurse should avoid moving the client back into bed until the seizure is completed. 17. A nurse is caring for an older adult client who was alert and oriented at admission, but now seems increasingly restless and intermittently confused. Which of the following actions should the nurse take to address the client's safety needs? a. Call the family and ask them to stay with the client. R It is the nurse's responsibility, not the family's, to ensure the client's during his time in the facility. b. Move the client to a room closer to the nurses' station. R This will make it easier for the staff to observe the client, should the client behave in an unsafe manner. c. Apply wrist and leg restraints to the client. R Restraints are a last resort, plus they can increase the client's risk for injury. d. Administer medication to sedate the client. R Sedating an older adult client can worsen confusion. 18. A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? a. Tachycardia R Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia (termed Cushing’s triad) are signs of increased ICP. b. Amnesia R The client who has a traumatic brain injury may experience a loss of consciousness along with a lack of memory of events prior to or following the injury, but does not indicate an increase in ICP. c. Hypotension R Alterations in vital signs, including increased systolic pressure, widening pulse pressure and bradycardia (termed Cushing’s triad) are signs of increased ICP. d. Restlessness R Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern. 19. A nurse is preparing to administer vaccines to a 1-year-old child. Which of the following vaccines should the nurse give? (Select all that apply.) a. Measles, mumps rubella (MMR) b. Diphtheria, tetanus and acellular pertussis (DTaP) c. Varicella (VAR) d. Rotavirus (RV) e. Human papillomavirus (HPV4) 20. A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings should the nurse expect a. Closed posterior fontanel b. Uses thumb and index fingers in a pincer grasp c. Lateral incisors d. Sitting steadily without support 21. A nurse is performing a pre-college physical assessment on an adolescent. Which of the following immunizations should the nurse anticipate administering? a. Pneumococcal polysaccharide vaccine b. Bacille Calmette-Guérin (BCG) vaccine c. Meningococcal polysaccharide vaccine d. Influenza vaccine 22. 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. Place the client in a semi-Fowler's position. b. Admit the client to a private room. c. Measure head circumference every shift. d. Implement seizure precautions. 23. A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care? a. Keep the infant NPO for 6 hr prior the procedure. b. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure. c. Place the infant in an infant seat for 2 hr following the procedure. d. Hold the infant's chin to his chest and knees to his abdomen during the procedure. 24. A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care? a. Provide respite services for the parents. b. Improve the client's communication skills. c. Foster self-care activities. d. Modify the environment. 25. A school nurse conducting a screening for pediculosis capitis identifies several children who require treatment. Which of the following instructions should the nurse give the children's parents? a. Soak all combs and hairbrushes in alcohol. b. Inspect any dogs or cats at home for lice. c. Seal nonwashable items in airtight plastic bags. d. Spray countertops and sinks with insecticide. 26. A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? a. Attempt to stop the seizure. b. Restrain the child's arms. c. Use a padded tongue blade. d. Position the child laterally. 27. A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? a. Prepare the child for a lumbar puncture. b. Administer an intravenous antibiotic. c. Obtain blood cultures. d. Place the child in isolation. 28. A nurse is caring for a child who has red marks across his cheeks. Which of the following actions should the nurse take? a. Assess the rest of the child's body for a rash. R Fifths Disease presents with erythema on the face, resembling slap marks. Further assessment on the child's body and extremities should be done to determine if the child has fifths disease. b. Refer the family to child protective services. c. Question the parents about how the marks occurred on the child's cheeks. d. Obtain the child's temperature. 29. A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority? a. Place a pillow under the child's head. b. Position the child side-lying. c. Loosen restrictive clothing. d. Clear the area of hazards. 30. A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse to say to the child? a. "I promise I won't tell anyone about this." b. "Let's discuss what happened with your family." c. "Your family is bad for doing this to you." d. "It is not your fault that this happened." 31. A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition? a. Tracks an object with eyes b. Sits with pillow props c. Smiles when a parent appears d. Uses a pincer grasp to pick up a toy 32. A nurse is reviewing the health history of a client who has a new prescription for a combined oral contraceptive (COC). The nurse recognizes that which of the following client medications can interfere with the effectiveness of the COC? a. Antihypertensives R Antihypertensives do not interfere with the effectiveness of COCs when taken simultaneously. b. Anticonvulsants R Anticonvulsants when taken simultaneously with COCs can decrease their effectiveness. The anticonvulsants included Inform the mother to notify the HCP of a temp greater than 101 degrees are: phenytoin, phenobarbital, carbamazepine, oxcarbazepine, topiramate, and primidone. c. Antioxidants R Antioxidants do not interfere with the effectiveness of COCs when taken simultaneously. d. Antiemetics R Antiemetics do not interfere with the effectiveness of COCs when taken simultaneously. 33. A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following should the infant receive? a. Hepatitis B immune globulin at 1 week followed by hepatitis B vaccine monthly for 6 months R This is not the appropriate vaccine and immune globulin schedule for a newborn whose mother is positive for the hepatitis B surface antigen. b. Hepatitis B vaccine monthly until the newborn tests negative for the hepatitis B surface antigen R This is not the appropriate vaccine and immune globulin schedule for a newborn whose mother is positive for the hepatitis B surface antigen. c. Hepatitis B immune globulin and hepatitis B vaccine within 12 hr of birth R A newborn whose mother is positive for the hepatitis B surface antigen should receive both the hepatitis B vaccine and the hepatitis B immune globulin within 12 hr of birth. d. Hepatitis B vaccine at 24 hr followed by hepatitis B immune globulin every 12 hr for 3 days R This is not the appropriate vaccine and immune globulin schedule for a newborn whose mother is positive for the hepatitis B surface antigen. 34. A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find? a. Over-riding suture lines R Newborns who have hydrocephalus will have widened suture lines and full or bulging fontanels due to pressure from the increased amount of cerebral spinal fluid. b. Dilated scalp veins R Manifestations of hydrocephalus in newborns include dilated scalp veins, separated sutures, and, in late infancy, frontal enlargement. c. Hypertension R Hydrocephalus increases pressure within the central nervous system, not within the cardiovascular system. Signs of increased pressure in the CNS include irritability, lethargy, and vomiting. d. A backward sloping appearance of the forehead. R This finding is associated with microcephaly, in which the newborn’s head is smaller due to inadequate brain growth. 35. A nurse is teaching a client who is at 23 weeks of gestation about immunizations. Which of the following statements should the nurse include in the teaching? a. "You should not receive the rubella vaccine while breastfeeding." R The client can safely receive the rubella vaccine while breastfeeding. b. "You should receive a varicella vaccine before you deliver." R The varicella vaccine should be administered after the client has delivered. She should avoid becoming pregnant for 28 days after receiving the vaccine. c. "You can receive an influenza vaccination during pregnancy." R It is recommended that pregnant women receive annual influenza vaccinations. d. "You cannot receive the Tdap vaccine until after you deliver." R The client can safely receive the tetanus, diphtheria, pertussis vaccine during pregnancy. 36. The pediatric clinic nurse is administering immunizations to a 2 month old infant. Which instructions should the nurse discuss with the mother? (Select all that apply.) a. Tell the mother slight redness at the injection site is expected b. Instruct the mother to give the infant a baby aspirin for comfort c. d. Explain the importance of keeping a record of her immunizations e. Discuss that the Haemophilus influenzae B vaccine will cause your baby to get the mid flu 37. What should be included in teaching a parent about the management of small red macules and vesicles that become pustules around the child's mouth and cheek? a. Keep the child home from school for 24 hours after initiation of antibiotic treatment. R To prevent the spread of impetigo to others, the child should be kept home from school for 24 hours after treatment is initiated. Good handwashing is imperative in preventing the spread of impetigo. b. Clean the rash vigorously with Betadine three times a day. R The lesions should be washed gently with a warm soapy washcloth three times a day. The washcloth should not be shared with other members of the family Items that cannot be washed should be dry cleaned or sealed in plastic bags for 2 to 3 weeks. c. Notify the physician for any itching. R Itching is common and does not necessitate medical treatment. Rather, parents should be taught to clip the child's nails to prevent maceration of the lesions. d. Keep the child home from school until the lesions are healed. R The child may return to school 24 hours after initiation of antibiotic treatment. 38. Parents of a child with lice infestation should be instructed carefully in the use of anti lice products because of which potential side effect? a. Nephrotoxicity R Anti Lice products are not known to be nephrotoxic. b. Neurotoxicity R Because of the danger of absorption through the skin and potential for neurotoxicity, anti lice treatment must be used with caution. A child with many open lesions can absorb enough to cause seizures. c. Ototoxicity R Anti Lice products are not ototoxic. d. Bone marrow depression R Products that treat lice are not known to cause bone marrow depression. 39. An important nursing consideration when caring for a child with impetigo contagiosa is to a. Apply topical corticosteroids to decrease inflammation. R Corticosteroids are not indicated in bacterial infections. b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris. R Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. c. Carefully wash hands and maintain cleanliness when caring for an infected child. R A major nursing consideration related to bacterial skin infections, such as impetigo contagiosa, is to prevent the spread of the infection and complications. This is done by thorough handwashing before and after contact with the affected child. d. Examine child under a Wood lamp for possible spread of lesions. R A Wood lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states, such as tinea capitis. 40. Impetigo ordinarily results in a. No scarring R Impetigo tends to heal without scarring unless a secondary infection occurs. b. Pigmented spots R Hyperpigmentation may occur; however, only in dark skinned children. c. Slightly depressed scars R No scarring usually occurs. d. Atrophic white scars R No scarring usually occurs 41. The primary clinical manifestation of scabies is a. Edema R Edema is not observed in scabies. b. Redness R Redness is not observed in scabies. c. Pruritus R Scabies is caused by the scabies mite. The inflammatory response and intense itching occur after the host has become sensitized to the mite. This occurs approximately 30 to 60 days after initial contact. In the previously sensitized person, the response occurs within 48 hours. d. Maceration R Maceration is not observed in scabies. 42. A nurse is instructing parents on treatment of pediculosis (head lice). Which should the nurse include in the teaching plan? Select all that apply. a. Bedding should be washed in warm water and dried on a low setting. b. After treating the hair and scalp with a pediculicide, shampoo the hair with regular shampoo. c. Retreat the hair and scalp with a pediculicide in 7 to 10 days. d. e. Combs and brushes should be boiled in water for at least 10 minutes. R An over-the-counter pediculicide, permethrin 1% (Nix, Elimite, Acticin), kills head lice and eggs with one application and has residual activity (i.e., it stays in the hair after treatment) for 10 days. Nix crème rinse is applied to the hair after it is washed with a conditioner-free shampoo. The product should be rinsed out after 10 minutes. Impetigo is highly contagious and can spread quickly. R The hair should not be shampooed for 24 hours after the treatment. Even though the kill rate is high and there is residual action, retreatment should occur after 7 to 10 days. Combs and brushes should be boiled or soaked in anti lice shampoo or hot water (greater than 60° C [140° F]) for at least 10 minutes. Advise parents to wash clothing (especially hats and jackets), bedding, and linens in hot water and dry at a hot dryer setting. 43. The nurse is presenting an in-service to a group of nurses who will be working in a dermatology clinic. One participant asks the nurse about a bacterial skin infection that she has seen in children. Which of the following disorders is the nurse most likely referring to? a. b. Miliaria rubra c. Candidiasis d. Seborrheic dermatitis 44. The nurse admits a child who has sustained a severe burn. The child's immunizations are up to date. Which of the following immunizations would the child most likely be given at this time? a. Tetanus toxoid vaccine R If inoculations are up to date, a booster dose of tetanus toxoid is required to protect the child from infection introduced into the burn. b. Hepatitis B vaccine c. Hepatitis A vaccine d. Haemophilus influenzae type B vaccine 45. The nurse is caring for an infant who has impetigo and is hospitalized. Which of the following nursing interventions is the highest priority for this child? a. The nurse applies topical antibiotics to the lesions. b. The nurse follows contact precautions. R Impetigo is highly contagious and can spread quickly. The nurse should follow contact (skin and wound) precautions, including wearing a cover gown and gloves. The nurse will soak the crusts with warm water, apply topical antibiotics, and apply elbow restraints, but these are not as high a priority as trying to prevent the spread of the infection by following contact precautions. c. The nurse applies elbow restraints to the infant. d. The nurse soaks the skin with warm water. 46. The nurse is working in a community setting and receives a call from a local day care center. One of the children in the center has been diagnosed with impetigo, and the director of the day care center wants to know whether she should be concerned. The nurse's response should reflect which of the following related to impetigo? a. Impetigo is a sexually transmitted infection and should be reported. b. Impetigo is usually caused because of sensitivity to pollens and molds. c. d. Impetigo cannot be treated with medication and has to run its course. 47. A child has been diagnosed with impetigo and the nurse is performing discharge teaching to the parents. Which statements by the parents indicate that additional teaching is necessary? Select all that apply. a. "Even though the lesions have crusted, the infection is contagious and our child should stay home from school." R Though impetigo is considered a contagious disorder among vulnerable populations, removal from school or day care is not necessary unless the condition is widespread or actively weeping. b. "Antifungal medications should be administered as ordered by our physician." R Impetigo is a bacterial not a fungal infection, therefore antibiotics will be ordered. c. "We should soak impetiginous lesions with cool compresses to remove crusts before applying topical medication." R Soaking and removing crusts is necessary for the medication to penetrate the infection. d. “Antibiotics should be spread out evenly so a constant level remains in the blood.” e. “Hand hygiene helps prevent spread of the infection” 48. 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 antiepileptic medications c. Corpus callosotomy d. Focal resection e. Radiation therapy 49. 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 Impetigo Influenza, live attenuated (LAIV) d. Low serum lead levels e. Presence of diphtheria 50. A nurse is providing teaching to the parent of a child who is to have an electroencephalogram (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." R Caffeine can alter the results of an EEG and should be avoided prior to the test. 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." 51. 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 R Loss of consciousness for 5 to 10 seconds is a manifestation of an absence seizure. b. Appearance of daydreaming R Behavior that resembles daydreaming is a manifestation of an absence seizure. c. Dropping held objects R A child who is having absence seizures might drop a held object. d. Falling to the floor e. Having a piercing cry 52. A nurse is providing care to a child who has an allergy to eggs. The nurse should question a prescription for which of the following immunizations? a. Hepatitis B (HepB) b. Haemophilus influenza type b (Hib) c. d. Inactivated poliovirus (IPV) Wong 1. Lindsey, age 5 years, will be starting kindergarten next month. She has cerebral palsy, and it has been determined that she needs to be in a special education classroom. Her parents are tearful when telling the nurse about this and state that they did not realize her disability was so severe. The best interpretation of this situation is that: a. This is a sign parents are in denial. b. This is a normal anticipated time of parental stress. R Parenting a child with a chronic illness can be stressful for parents. There are anticipated times that parental stress increases. One of these identified times is when the child begins school. Nurses can help parents recognize and plan interventions to work through these stressful periods. c. The parents need to learn more about cerebral palsy. d. The parents are used to having expectations that are too high. 2. Families progress through various stages of reactions when a child is diagnosed with a chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by which of the following responses? a. Denial b. Guilt and anger R For most families, the adjustment phase is accompanied by several responses. Guilt, self- accusation, bitterness, and anger are common reactions. The initial diagnosis of a chronic illness or disability often is met with intense emotion, characterized by shock and denial. Social reintegration and acceptance of the child’s limitations are the culmination of the adjustment process. c. Social reintegration d. Acceptance of child’s limitations 3. The nurse observes that a seriously ill child passively accepts all painful procedures. The nurse should recognize that this is most likely an indication that the child is experiencing a: a. sense of hopefulness. b. sense of chronic sorrow. c. belief that procedures are a deserved punishment. R The nurse should be particularly alert to the child who passively accepts all painful procedures. This child may believe that such acts are inflicted as deserved punishment. The child who is hopeful is mobilized into goal-directed actions. This child would actively participate in care. Chronic sorrow is the feeling of sorrow and loss that recurs in waves over time. It is usually evident in the parents, not in the child. A child who believes that procedures are an important part of care would actively participate in care. Nursing interventions should be used to minimize the pain. d. belief that procedures are an important part of care. 4. The nurse comes into the room of a child who was just diagnosed with a chronic disability. The child’s parents begin to yell at the nurse about a variety of concerns. Which is the nurse’s best response? a. “What is really wrong?” b. “Being angry is only natural.” R Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most common targets for parental anger is members of the staff. The nurse should recognize the common response of anger to the diagnosis and allow the family to ventilate. “What is really wrong?”/“Yelling at me will not change things”/“I will come back when you settle down” will place the parents on the defensive and not facilitate communication c. “Yelling at me will not change things.” d. “I will come back when you settle down.” 5. Which intervention will encourage a sense of autonomy in a toddler with disabilities? a. Avoid separation from family during hospitalizations. b. Encourage independence in as many areas as possible. R Encouraging the toddler to be independent encourages a sense of autonomy. The child can be given choices about feeding, dressing, and diversional activities, which will provide a sense of control. c. Expose child to pleasurable experiences as much as possible. d. Help parents learn special care needs of their child. 6. The feeling of guilt that the child “caused” the disability or illness is especially critical in which child? a. Toddler b. Preschooler c. School-age child d. Adolescent 7. A 9-year-old boy has several physical disabilities. His father explains to the nurse that his son concentrates on what he can, rather than cannot, do and is as independent as possible. The nurse’s best interpretation of this is that the: a. father is experiencing denial. b. father is expressing his own views. c. child is using an adaptive coping style. R The father is describing a well-adapted child who has learned to accept physical limitations. These children function well at home, at school, and with peers. They have an understanding of their disorder that allows them to accept their limitations, assume responsibility for care, and assist in treatment and rehabilitation. d. child is using a maladaptive coping style. 8. The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The parent is upset and tearful. The nurse asks, “Whom do you talk to when something is worrying you?” This should be interpreted as: a. inappropriate, because the parent is so upset. b. a diversion of the present crisis to similar situations with which the parent has dealt. c. an intervention to find someone to help the parent. d. part of assessing the parent’s available support system. R These are important data for the nurse to obtain. This question will provide information about the marital relationship (whether the parent speaks to the spouse), alternate support systems, and ability to communicate. By assessing these areas, the nurse can facilitate the identification and use of community resources as needed. 9. The nurse is providing support to parents at the time their child is diagnosed with chronic disabilities. The nurse notices that the parents keep asking the same questions. What is the nurse’s best intervention? a. Patiently continue to answer questions. R Diagnosis is one of the anticipated stress points for parents. The parents may not hear or remember all that is said to them. The nurse should continue to provide the kind of information they desire. b. Kindly refer them to someone else for answering their questions. c. Recognize that some parents cannot understand explanations. d. Suggest that they ask their questions when they are not upset. 10. Which is the most appropriate nursing intervention to promote normalization in a school-age child with a chronic illness? a. Give child as much control as possible. R The school-age child who is ill may be forced into a period of dependency. To foster normalcy, the child should be given as much control as possible. b. Ask child’s peer to make child feel normal. c. Convince child that nothing is wrong with him or her. d. Explain to parents that family rules for the child do not need to be the same as for healthy siblings. 11. Nursing interventions to help the siblings of a child with special needs cope include: a. explaining to the siblings that embarrassment is unhealthy. b. encouraging the parents not to expect siblings to help them care for the child with special needs. c. providing information to the siblings about the child’s condition only as they request it. d. suggesting to the parents ways of showing gratitude to the siblings who help care for the child with special needs. R The presence of a child with special needs in a family will change the family dynamic. Siblings may be asked to take on additional responsibilities to help the parents to care for the child. The parents should show gratitude, such as an increase in allowance, special privileges, and verbal praise 12. The parents of a child born with disabilities ask the nurse for advice about discipline. The nurse’s response should be based on knowledge that discipline is: a. essential for the child. R Discipline is essential for the child. It provides boundaries on which to test out their behavior and teaches them socially acceptable behaviors. The nurse should teach the parents ways to manage the child’s behavior before it becomes problematic. Punishment is not effective in managing behavior. b. too difficult to implement with a special-needs child. c. not needed unless child becomes problematic. d. best achieved with punishment for misbehavior. 13. Kelly, an 8-year-old girl, will soon be able to return to school after an injury that resulted in several severe, chronic disabilities. Which is the most appropriate action by the school nurse? a. Recommend that the child’s parents attend school at first to prevent teasing. b. Prepare the child’s classmates and teachers for changes they can expect. R Attendance at school is an important part of normalization for Kelly. The school nurse should prepare teachers and classmates about her condition, abilities, and special needs. A visit by the parents can be helpful, but unless the classmates are prepared for the changes, it alone will not prevent teasing. Kelly’s school experience should be normalized as much as possible. c. Refer the child to a school where the children have chronic disabilities similar to hers. R Discuss with the child and her parents the fact that her classmates will not accept her as they did before. 14. A 16-year-old boy with a chronic illness has recently become rebellious and is taking risks such as missing doses of his medication. The nurse should explain to his parents that: a. he needs more discipline. b. he needs more socialization with peers. c. this is part of normal adolescence. d. this is how he is asking for more parental control. 15. At what developmental period do children have the most difficulty coping with death, particularly if it is their own? a. Toddlerhood b. Preschool c. School-age d. Adolescence R Adolescents, because of their mature understanding of death, remnants of guilt and shame, and issues with deviations from normal, have the most difficulty coping with death. 16. Which describes avoidance behaviors parents may exhibit when learning that their child has a chronic condition? (Select all that apply.) a. Refuses to agree to treatment b. Shares burden of disorder with others c. Verbalizes possible loss of child d. Withdraws from outside world e. Punishes self because of guilt and shame 17. Which are adaptive coping patterns used by children with special needs? (Select all that apply.) a. Feels different and withdraws b. Is irritable, moody, and acts out c. Seeks support d. Develops optimism NCLEX (seizures) 1. Client is having tonic-clonic seizure. Nurse should take which of the following actions? Select all that apply. a. Restrain client b. Maintain airway. c. Turn client to side. d. Place tongue blade in mouth e. Protect client from injury. 2. The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse is contraindicated? a. loosening restrictive clothing b. restraining the clients limbs c. removing the pillow and raising padded side rails d. positioning the client to the side, if possible, with the head flexed forward 3. The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning care for the client's safety? Select all that apply a. b. c. placing the bed in the high position d. putting a padded tongue blade at the head of the bed e. placing oxygen and suction equipment at the bed side f. having intravenous equipment ready for insertion of an intravenous catheter 4. A nurse is assessing a client who has seizure disorder. the client reports he thinks he is out to have a seizure. which of the following actions should the nurse implement (select all that apply) a. provide privacy b. ease the client to the floor if standing c. move furniture away from the client d. loosen the clients clothing e. protect the clients head with padding f. restrain the client 5. A nurse is caring for a client who just experienced a generalized seizure. Which of the following actions should the nurse perform first? a. keep the client in a side lying position b. document the duration of the seizure c. reorient the client to the environment d. provide client hygiene 6. A nurse is providing discharge instructions to a female client who has a prescription for phenytoin. Which of the following information should the nurse include? a. consider taking oral contraceptives when on this medication b. watch for receding gums when taking this medication c. take the medication at the same time everyday d. provide a urine sample to determine therapeutic levels of the medication 7. A nurse is reviewing trigger factors that can cause seizures with a client who has a new diagnosis of generalized seizures. Which of the following information should the nurse include in this review? (select all that apply) a. avoid overwhelming fatigue placing an airway at the bedside padding the side rails of the bed b. remove caffeinated products from the diet c. limit looking at flashing lights d. perform aerobic exercise e. limit episodes of hypoventilation f. use of aerosol hairspray is recommended 8. A nurse is completing discharge teaching to a client who has seizures and received a vagal nerves stimulator to decrease seizure activity. Which of the following statements should the nurse include in the teaching? a. it is safe to use microwave that are 1200 watts or less b. you should avoid the use of CT scans with contrast c. you should place a magnet over the implantable device when you feel an aura occurring d. it is recommended that you use ultrasound diathermy for pain management 9. A 6-year-old child is seen in the urgent care unit for a history of seizures at home. He begins to have seizures in the urgent care unit that last more than 5 minutes. IV access has not been successful. The nurse caring for this child is knowledgeable that either of these medications may be given to stop the child's seizures: a. IM phenytoin b. Rectal diazepam c. Buccal midazolam d. a and c e. b and c 10. The nurse creates a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside? a. Emergency cart b. Tracheotomy set c. Padded tongue blade d. Suctioning equipment and oxygen 11. The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply. a. Time the seizure. b. Restrain the child. c. Stay with the child. d. Place the child in a prone position. e. Move furniture away from the child. f. Insert a padded tongue blade in the child's mouth. 12. The nurse is caring for a client who begins to experience seizure activity while in bed. Which actions should the nurse take?Select all that apply. a. Loosening restrictive clothing b. Restraining the client's limbs c. Removing the pillow and raising padded side rails d. Positioning the client to the side, if possible, with the head flexed forward e. Keeping the curtain around the client and the room door open so when help arrives they can quickly enter to assist 13. The nurse is instituting seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. a. b. c. Placing the bed in the high position d. Putting a padded tongue blade at the head of the bed e. Placing oxygen and suction equipment at the bedside f. Flushing the intravenous catheter to ensure that the site is patent 14. Which drug used in the treatment of seizures requires careful monitoring of renal function? a. Lamotrigine (Lamictal) b. Primidone (Mysoline) Placing an airway at the bedside Padding the side rails of the bed Specific odors Increased seizure activity c. Carbamazepine (Tegretol) d. Valproic acid (Depakene) 15. A patient taking phenytoin (Dilantin) and isoniazid reports feeling lethargic. Nystagmus is noted on physical examination. What problem does this information suggest to the nurse? a. Tubercular reactivation b. Abrupt discontinuation of isoniazid c. Phenytoin toxicity d. Liver damage 16. Which antiepileptic drug is effective for almost all forms of seizures? a. Valproic acid (Depakene) b. Carbamazepine (Tegretol) c. Phenobarbital (Luminal) d. Phenytoin (Dilantin) 17. A patient with diabetes is started on phenytoin (Dilantin) for partial seizures. What does the nurse closely monitor in this individual? a. Blood pressure b. Hypoglycemia c. Hyperglycemia d. Weight loss 18. A patient taking phenytoin (Dilantin) has started attending college and reports frequently drinking alcohol with friends. What does the nurse monitor for in this patient? a. Clinical manifestations of phenytoin toxicity b. Hyperglycemia c. Hypertension d. 19. Which measurement is the best indicator of how well an anti seizure medication is working? a. Serum drug levels b. Frequency and duration of seizures c. Liver enzymes d. Urinary output 20. In which patient is carbamazepine (Tegretol) contraindicated? a. Patient with new onset of seizures b. Patient with an ulcer c. Patient with chronic hepatitis B d. Patient with diabetes mellitus 21. A patient has been started on lamotrigine (Lamictal). How does the nurse instruct this patient to take the medication to decrease the incidence of gastric irritation? a. With milk or food b. Between meals with a glass of orange juice c. At bedtime d. One hour before meals or 2 hours after meals 22. A client asks the nurse what might trigger a seizure. Which situation should the nurse include in the response? a. Exposure to toxins b. Decreased intracranial pressure c. Low body temperature d. Low blood pressure 23. The nurse is teaching a client about possible seizure triggers. Which information should the nurse include? (Select all that apply.) a. b. c. d. Lactose consumption e. Fever Menstruation Flashing lights Triggers for seizures 24. A client reports that they usually have a seizure on the first day of their period. Which response by the nurse is correct? a. "Having your period has no relationship to your seizures." b. "Menstruation is a common trigger for seizures." c. "What makes you think having your period is related?" d. "Females who have a lot of menstrual cramps often have seizure activity." 25. The nurse is planning discharge teaching for a 30-year-old female client who was newly diagnosed with tonic-clonic seizures. Which information should the nurse include in this teaching plan? (Select all that apply.) a. b. c. Keeping a padded tongue blade at home in case of a seizure d. Taking showers rather than tub baths e. Monitoring the menstrual cycle 26. The nurse is caring for a client with a seizure disorder currently controlled with anti seizure medication. The client states, "A friend recommended an herbal supplement for my depression. Can I take it?" Which response by the nurse is correct? a. "St. John's wort has been known to decrease the effectiveness of your antiseizure medication." b. "You can take valerian along with your antiseizure medication to help you sleep." c. "You should avoid garlic, because it can decrease the effectiveness of your antiseizure medication." d. "Essential oils would be a better option with your anti seizure medication." 27. A client's mother asks the nurse if there is anything non-pharmacologic that her daughter can do to help with intractable seizures. Which response by the nurse is correct? a. "Taking megadoses of vitamins might be worth a try." b. "Eating a vegetarian diet has been proven to be successful." c. "Taking in extra sugar on a regular basis could be helpful." d. "Eating a ketogenic diet can be helpful." 28. Which complementary health approach may be specifically tailored to assist in the identification of the warning signs of seizures? a. Behavior modification b. Massage c. Biofeedback d. Meditation 29. Medication has been ineffective in controlling a client's seizures. Which treatment option should the nurse suspect will be discussed with the client? a. Surgical resection b. Herbal remedies c. More sleep d. Head massage 30. The nurse is admitting a client with a history of frequent tonic-clonic seizures. Which information would be most valuable for the nurse to obtain when performing the health history assessment? (Select all that apply.) a. Presence of auras b. Incontinence during seizure c. d. e. Duration of seizures 31. Which assessment data should the nurse obtain when completing a health history on a client with a seizure disorder? a. Vital signs b. Level of consciousness c. Neurologic exam d. Presence of auras 32. The nurse is conducting a home visit for a 6-year-old client who has myoclonic and absence seizures. The parents are following a ketogenic diet for the child. Which observation requires follow-up by the nurse? a. Parents administer medium-chain-triglyceride (MCT) oil as needed. b. Parents include low carbohydrate foods. Age of seizure onset Avoiding driving while taking anti seizure medication Wearing a bracelet that provides health information Oxygen mask Suction tubing Inspect the oral mucosa. c. Parents include low-fat foods for each meal. d. Parents monitor urine ketone levels regularly. 33. A patient has a tonic-clonic seizure while the nurse is in the patient's room. Which action should the nurse take? a. Insert an oral airway during the seizure to maintain a patent airway. b. Restrain the patient's arms and legs to prevent injury during the seizure. c. Avoid touching the patient to prevent further nervous system stimulation. d. Time and observe and record the details of the seizure and postictal state. 34. Which action will the nurse take when evaluating a patient who is taking phenytoin (Dilantin) for adverse effects of the medication? a. b. Listen to the lung sounds. c. Auscultate the bowel tones. d. Check pupil reaction to light. 35. The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to a. assess the patient for a possible head injury. b. give the scheduled dose of divalproex (Depakote). c. document the timing and description of the seizure. d. notify the patient's health care provider about the seizure. 36. Which of these prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonicclonic seizures? a. Give phenytoin (Dilantin) 100 mg IV. b. Monitor level of consciousness (LOC). c. Obtain computed tomography (CT) scan. d. Administer lorazepam (Ativan) 4 mg IV. 37. When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room (select all that apply)? a. Side Rail pads b. Tongue blade c. d. e. Nasogastric tube 38. Which characteristic of a patient's recent seizure indicates a partial seizure? a. The patient lost consciousness during the seizure. b. The seizure involved lipsmacking and repetitive movements. c. The patient fell to the ground and became stiff for 20 seconds. d. The etiology of the seizure involved both sides of the patient's brain. 39. The patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. You immediately assess the patient for a. an aura. b. nystagmus or confusion. c. abdominal pain or cramping. d. irregular pulse or palpitations 40. During the postictal period of a seizure, you would expect the patient to a. demonstrate minor jerking and eye fluttering. b. sleep for several hours. c. be incontinent of urine and feces. d. require ventilator assistance. 41. you recognize that status epilepticus is a medical emergency because a. seizures continue without a return of consciousness. b. fractures of a limb may occur. c. urinary fecal incontinence may occur. lorazepam (Ativan) diazepam (Valium) d. heart rate becomes bradycardic. 42. The patient is seen in the clinic due to an increase in the frequency of seizure activity. In addition to a thorough health history you should draw blood for a. Anemia. b. serum drug levels. c. arterial blood gases. d. Electrolytes. 43. Treatment of status epilepticus requires initiation of a rapid-acting antiseizure drug that can be given intravenously. You would anticipate which drugs to be administered (select all that apply)? a. phenytoin (Dilantin) b. phenobarbital c. d. e. carbemazepine (Tegretol) 44. A male client is having a tonic-clonic seizures. What should the nurse do first? a. Elevate the head of the bed. b. Restrain the client's arms and legs. c. Place a tongue blade in the client's mouth. d. Take measures to prevent injury 45. The nurse is caring for a child who had a seizure 15 minutes after sustaining a head injury. After assuring a patent airway, which of the following is the priority intervention? a. Assess fluid and electrolyte status b. Administer prescribed benzodiazepine c. Monitor for postconcussive syndrome d. Observe for signs of increased intracranial pressure 46. The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an understanding of the information about this medication? a. "I need to perform good oral hygiene, including flossing and brushing my teeth." b. "I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." c. "I should take my medication before coming to the laboratory to have a blood level drawn." d. "I should monitor for side effects and adjust my medication dose depending on how severe the side effects are.” 47. The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? a. b. IV diazepam (Valium) c. IV phenytoin (Dilantin) d. Oral carbamazepine (Tegretol) 48. The nurse giving discharge teaching for a client receiving carbamazepine (Tegretol) should include: a. Monitor blood glucose, and report decreased levels. b. Expect a discoloration of the contact lenses. c. Expect an orange discoloration of urine. d. Report unusual bleeding or bruises to the health care provider immediately. 49. The nurse completes a history and physical on a client admitted with exacerbation of a seizure disorder. What data collected by the nurse requires intervention? a. History of asthma b. History of diabetes mellitus c. Use of herb Ginkgo biloba d. Use of aspirin daily 50. The client, age 8, is prescribed valproic acid (Depokene) for treatment of a seizure disorder. The nurse should monitor the client closely for: a. Vitamin B deficiency. IV dextrose solution b. Restlessness and agitation. c. Hyperthermia. d. Respiratory distress 51. A client receiving phenytoin (Dilantin) has been experiencing fluctuating serum blood levels of the medication. Development of which symptoms in the client should prompt the nurse to notify the primary health care provider immediately? (Select all that apply.) a. GI cramping and diarrhea b. Migraine headaches and nausea c. Dry skin and constipation d. Double vision and lethargy NCLEX (GBS) 1. Which assessment data should the nurse assess in the client diagnosed with Guillain-Barré syndrome? a. An exaggerated startle reflex and memory changes. R These signs/symptoms, along with sleep disturbances and nervousness, support the diagnosis of Creutzfeldt-Jakob disease. b. Cogwheel rigidity and inability to initiate voluntary movement. R These signs/symptoms support the diagnosis of Parkinson's disease. c. Sudden severe unilateral facial pain and inability to chew. R These are signs/symptoms of trigeminal neuralgia. d. Progressive ascending paralysis of the lower extremities and numbness. R Ascending paralysis is the classic symptom of Guillain-Barré syndrome 2. Which statement by the client supports the diagnosis of Guillain-Barré syndrome? a. "I just ret