Page 1125 - Saunders Comprehensive Review For NCLEX-RN

is the priority nursing intervention in the preoperative period?
1. Test the urine for protein.
2. Reposition the infant frequently.
3. Provide a stimulating environment.
4. Assess blood pressure every 15 minutes.
392. 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.
1. Time the seizure.

2. Restrain the child.

3. Stay with the child.

4. Place the child in a prone position.

5. Move furniture away from the child.

6. Insert a padded tongue blade in the child’s mouth.

Answers

382. Answer: 3

Rationale: Cerebral palsy is a chronic disability characterized by impaired
movement and posture resulting from an abnormality in the extrapyramidal or
pyramidal motor system. Meningitis is an infectious process of the central nervous
system. Encephalitis is an inflammation of the brain that occurs as a result of viral
illness or central nervous system infection. Down’s syndrome is an example of a
congenital condition that results in moderate to severe intellectual disabilities.
Test-Taking Strategy: Eliminate options 1 and 2 first, noting that they are
comparable or alike. Next, note the relationship between the words palsy in the
question and impaired muscle movement in the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Pediatrics: Neurological
Health Problem: Pediatric-Specific: Cerebral Palsy
Priority Concepts: Intracranial Regulation; Mobility
Reference: Hockenberry, Wilson, Rodgers (2017), pp. 979-980.

383. Answer: 1

Rationale: Meningitis is an infectious process of the central nervous system
caused by bacteria and viruses. The inability to extend the leg when the thigh is
flexed anteriorly at the hip is a positive Kernig’s sign, noted in meningitis. Kernig’s
sign is not seen specifically with spinal cord injury, intracranial bleeding, or
decreased cerebral blood flow.
Test-Taking Strategy: Note the data in the question and the subject, the

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