a 7 year old child has an altered mental status high fever and a generalized rash you perform your assessment and initiate oxygen therapy en route to
Logo

Nursing Elites

HESI LPN

Pediatrics HESI 2023

1. A 7-year-old child has an altered mental status, high fever, and a generalized rash. You perform your assessment and initiate oxygen therapy. En route to the hospital, you should be most alert for

Correct answer: B

Rationale: Seizures are a common complication in children with high fever and altered mental status, indicating a risk of febrile seizures. While vomiting can occur with altered mental status, seizures are of higher concern due to the association with febrile illnesses in children. Combativeness may be a concern in some altered mental status cases but is not as common as seizures. Respiratory distress, although important, is not the primary concern in this scenario given the symptoms presented.

2. During a vaccination drive at a well-child clinic, a nurse observes that a recently hired nurse is not wearing gloves. What should the nurse advise the newly hired nurse to do?

Correct answer: B

Rationale: The correct answer is B: Put on gloves because standard precautions are required. Standard precautions, which include wearing gloves, are crucial in preventing the transmission of infections during immunization. Choice A is incorrect because the immediate action should be to address the lack of gloves. Choice C is incorrect as gloves are necessary for infection control. Choice D is incorrect as gloves should be worn as a standard preventive measure, regardless of the child's appearance.

3. A newborn is admitted to the neonatal intensive care unit (NICU) with choanal atresia. Which part of the infant’s body should the nurse assess?

Correct answer: B

Rationale: Choanal atresia is a congenital condition characterized by the blockage of the nasal passages, specifically the choanae that connect the nasal cavity to the nasopharynx. The nurse should assess the nasopharynx to identify any obstruction, confirm the diagnosis, and assess the severity of the condition. Choices A, C, and D are incorrect as they do not pertain to choanal atresia. Choanal atresia specifically involves the nasal passages and nasopharynx, not the rectum, intestinal tract, or laryngopharynx.

4. The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?

Correct answer: A

Rationale: The correct answer is A: Risk for impaired skin integrity due to cast and location. When caring for a child with a long-leg hip spica cast, the priority nursing diagnosis is the risk for impaired skin integrity. This is because the child's limited mobility and the pressure from the cast can lead to skin breakdown and complications. Choice B is incorrect as while education is essential, it is not the priority when immediate physical risks are present. Choice C is incorrect because while immobility can impact development, the immediate concern is preventing complications from the cast. Choice D is incorrect as it focuses on self-care deficits rather than the physical risk of skin integrity issues.

5. A child is brought to the clinic after tripping over a rock. The child states, 'I twisted my ankle,' and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?

Correct answer: A

Rationale: The correct intervention for a sprained ankle is to apply ice for 20 minutes every hour for the first 24 hours, then remove for 60 minutes to prevent tissue damage. This regimen helps reduce swelling and pain. Bed rest with the leg elevated for an extended period (36 hours) may lead to stiffness and decreased range of motion. While NSAIDs can be used for pain, they may not be necessary if pain is manageable with ice and rest. Using a compression dressing for 72 hours continuously may impede proper circulation and delay healing by restricting blood flow.

Similar Questions

The nurse is assessing a 3-year-old boy whose parents brought him to the clinic when they noticed that the right side of his abdomen was swollen. What finding would suggest this child has a neuroblastoma?
A child with a diagnosis of hemophilia is admitted to the hospital with a bleeding episode. What is the priority nursing intervention?
When administering IV fluids to a dehydrated infant, what intervention is most important at this time?
A child sitting on a chair in a playroom starts to have a tonic-clonic seizure with a clenched jaw. What is the nurse’s best initial action?
The parents of a child who has just been diagnosed with type 1 diabetes ask about exercise. What should the nurse explain about exercise in type 1 diabetes?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses