A&C I Practice Neuro musculoskeletal

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take?

Assess the client's airway patency Remove objects from the client's bed Place the client in side lying position

A nurse is planning care for a y/o child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

Measure head circumference every shift. The head circumference of a 6-year-old can't increase since the fontanels and sutures have been closed since the child was 18 months old. Therefore, it is unnecessary to measure the child's head circumference.

A nurse is assessing a client who has Bell's Palsy. Which of the following findings should the nurse expect?

Muscle distortion is correct. Pain behind the ear is correct Impaired taste is correct

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include?

Provide a suction setup at the bedside Elevate the side rails near the head when the client is in bed Place the bed in the lowest position Keep an oxygen setup at the bedside is correct

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Brudzinski's sign This client is manifesting a positive Brudzinski's sign, which is indicated when the hips and knees flex when neck is flexed. A positive Brudzinski's sign is a common sign of meningitis.

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?

Place the child in isolation Bacterial meningitis is highly contagious. Therefore, the nurse should protect others from infection by placing the child in isolation.

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?

Place the client on his side. 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.

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?

Position the child side-lying. This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

Severe headache The nurse should expect a client who has meningitis to manifest a severe headache due to meningeal inflammation.

A nurse is assessing an 8-month old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?

Sits with pillow props Infants who have cerebral palsy require support when sitting upright.