Question

You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)

Answer 1

Correct Answers:

Remove restrictive objects or clothing from patients’ body
Oxygen and suction at bedside
Padded bed rails

Rationale :

Remove restrictive objects or clothing:

🟣Seizure precautions aim to reduce trauma and airway compromise during involuntary movements.

🟣Removing tight clothing, ties, scarves, or sharp accessories prevents neck constriction and skin injury.

🟣Loose clothing makes it easier to position the patient into a side-lying (recovery) position if a seizure occurs.

🟣It also facilitates rapid assessment of breathing and circulation. Minimizing external hazards is a core element of environmental safety for seizure-risk patients.

Oxygen and suction at bedside:

🟣Immediate access to oxygen addresses post-ictal hypoxemia, while suction allows prompt removal of secretions, saliva, or emesis that can obstruct the airway.

🟣Keeping equipment set up and functional prevents dangerous delays.

🟣These supplies support the primary goal of seizure care—airway, breathing, circulation (ABC).

🟣Ready equipment empowers the nurse to act within seconds, which is critical in prolonged or clustered seizures.

🟣This preparation is a standard protocol in seizure precautions.

Padded bed rails:

🟣Padding prevents lacerations, contusions, and fractures caused by repeated impact against rails during tonic–clonic activity.

🟣Padded rails also help maintain a safe boundary without restraining the patient.

🟣They reduce the risk of head injury if the patient turns abruptly.

🟣Using padding is a non-restrictive safety measure consistent with least-restraint principles.

🟣Bedside padding is widely recognized as best practice in inpatient seizure precautions.

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Answer 2

Correct Answers:

"My belly doesn't hurt anymore."

Rationale :

🔷In a child with suspected appendicitis, sudden relief of pain may indicate rupture of the appendix, which is a surgical emergency.

🔷A ruptured appendix releases infectious material into the peritoneal cavity, placing the child at risk for peritonitis and sepsis.

🔷This is the most concerning finding and requires immediate intervention.

🔷Persistent pain is expected until surgical removal, so resolution of pain before treatment is highly suspicious.

🔷Nurses must report this finding right away to the provider for urgent evaluation and management.

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Answer 3

Correct Answers:

"Encourage your child to avoid sharing hats with other children."

Rationale :

🟡Head lice are spread by direct contact and sharing of personal items such as hats, combs, and scarves.

🟡Teaching parents to prevent sharing headwear reduces the risk of transmission in school-age children.

🟡Lice do not jump or fly but crawl from one host to another, making shared objects the most common transmission route.

🟡Preventive teaching is essential for controlling outbreaks in community settings such as schools.

🟡This teaching empowers parents to take simple but effective steps to keep their child free of lice.

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Answer 4

Correct Answers:

Periorbital edema

Rationale :

🔴Nephrotic syndrome is characterized by massive proteinuria, which reduces plasma oncotic pressure and leads to fluid shift into tissues.

🔴The most common early manifestation is periorbital edema, especially noticeable in the morning.

🔴As the condition progresses, generalized edema (anasarca) may develop due to ongoing fluid retention.

🔴Hypoalbuminemia and hyperlipidemia are additional hallmarks of nephrotic syndrome.

🔴Recognizing periorbital edema helps the nurse identify nephrotic syndrome early for prompt management.

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Answer 5

Correct Answers:

Eggs

Rationale :

⚫The influenza vaccine is traditionally prepared using egg protein, making an egg allergy a contraindication or requiring special precautions.

⚫Severe reactions such as anaphylaxis may occur in patients with egg allergies if the vaccine is administered.

⚫Nurses must always review allergies before administering vaccines to prevent life-threatening complications.

⚫Although newer formulations exist that are egg-free, standard practice is to avoid the flu shot in those with egg hypersensitivity unless otherwise directed by the provider.

⚫This highlights the importance of thorough allergy history before immunization in pediatrics.

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Answer 6

Correct Answers:

Tugging on the affected ear lobe

Rationale :

🟢Infants with otitis media often tug, pull, or rub their affected ear due to ear pain and pressure.

🟢They cannot verbalize discomfort, so this behavior is a primary clinical cue for caregivers and nurses.

🟢Otitis media is also associated with irritability, fever, and sometimes difficulty sleeping.

🟢Identifying this subtle sign ensures early treatment to prevent complications such as hearing loss.

🟢It is one of the most reliable observable symptoms in non-verbal children.

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Answer 7

Correct Answers:

Change to cloth diapers until the skin is healed.

Rationale :

🔵Diaper dermatitis is worsened by exposure to chemicals in disposable diapers and prolonged moisture.

🔵Using cloth diapers temporarily reduces skin irritation and allows for frequent changes, keeping the area dry.

🔵Management also includes gentle cleansing and use of barrier creams to protect against further breakdown.

🔵Avoidance of powders and irritants is important since they may worsen skin inflammation.

🔵Nurses must educate caregivers on maintaining skin integrity and comfort during healing.

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Answer 8

Correct Answers:

Puzzle games

Rationale :

🟣After an orchiopexy (surgical correction of undescended testes), activities should be low-risk and non-strenuous.

🟣Puzzle games promote rest, focus, and safe engagement without risking injury to the surgical site.

🟣Activities such as running or sports may cause strain on sutures and delayed healing.

🟣Choosing calm, seated activities supports recovery while still stimulating the child mentally.

🟣This minimizes complications and supports a smooth healing process.

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Answer 9

Correct Answers:

Administer pain medication 30 min before physical therapy.

Rationale :

♦Pain control is critical in children with burns, especially before physical therapy, which can be painful due to stretching and movement.

♦Administering analgesics 30 minutes before therapy ensures peak effect during the session, improving tolerance.

♦Adequate pain relief promotes cooperation and better rehabilitation outcomes.

♦Poorly managed pain can lead to anxiety, decreased participation, and long-term mobility issues.

♦This intervention demonstrates the nurse’s role in anticipatory care and comfort promotion.

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Answer 10

Correct Answers:

"My child will outgrow this by the time he is 2 years old and be able to see just fine."

Rationale :

⭐Strabismus does not typically resolve spontaneously by age 2, and untreated cases may result in amblyopia (lazy eye) or permanent vision impairment.

⭐The primary treatment involves eye patching the stronger eye to strengthen the weaker one, and if this fails, surgical correction may be necessary.

⭐Believing the child will “outgrow it” demonstrates misunderstanding of the condition’s seriousness.

⭐Early intervention is crucial since the visual system develops rapidly in early childhood.

⭐Nurses must correct this misconception to prevent long-term vision complications.

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ATI NS122 Pediatric Monroe College

No.

1 :
You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)

2 :
A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?

3 :
A nurse is reinforcing teaching about lice with the parents of a school-age child at a well-child visit. Which of the following information should the nurse include?

4 :
A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect?

5 :
A 24 month old comes into the clinic to get his first flu vaccination. The nurse notices what food allergy in the patient's chart that would make this vaccine contraindicated?

6 :
A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?

7 :
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?

8 :
Which of the following activities are appropriate for a child who is recovering from orchiopexy?

9 :
A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include?

10 :
The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?

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ATI NS122 Pediatric Monroe College

No.

1 : You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)

2 : A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?

3 : A nurse is reinforcing teaching about lice with the parents of a school-age child at a well-child visit. Which of the following information should the nurse include?

4 : A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect?

5 : A 24 month old comes into the clinic to get his first flu vaccination. The nurse notices what food allergy in the patient's chart that would make this vaccine contraindicated?

6 : A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?

7 : A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?

8 : Which of the following activities are appropriate for a child who is recovering from orchiopexy?

9 : A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include?

10 : The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?

1 :
You have a patient who has a brain tumor and is at risk for seizures. In the patient's plan of care you incorporate seizure precautions. Select the 3 choices below for all the proper steps to take in initiating seizure precautions. (Select All that Apply.)

2 :
A school-age child in an emergency department has a 2-day history of nausea and vomiting and reports severe right lower quadrant pain. A nurse is preparing the child for an appendectomy. Which of the following statements by the child should the nurse find most concerning?

3 :
A nurse is reinforcing teaching about lice with the parents of a school-age child at a well-child visit. Which of the following information should the nurse include?

4 :
A nurse is collecting data from a child who has nephrotic syndrome. Which of the following manifestations should the nurse expect?

5 :
A 24 month old comes into the clinic to get his first flu vaccination. The nurse notices what food allergy in the patient's chart that would make this vaccine contraindicated?

6 :
A nurse is collecting data from an infant who has otitis media. The nurse should expect which of the following findings?

7 :
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?

8 :
Which of the following activities are appropriate for a child who is recovering from orchiopexy?

9 :
A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include?

10 :
The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?