While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: "Observe for prolonged periods of apnea." The nurse's first priority during a seizure is to ensure the client's airway remains clear and that they are breathing adequately. Prolonged periods of apnea can lead to hypoxia, which can be life-threatening. By closely monitoring the client's breathing, the nurse can intervene promptly if respiratory distress occurs. Option A, documenting details of the seizure activity, is important for the client's medical record but is not the most immediate concern during an active seizure. Option B, observing for lacerations to the tongue, is important post-seizure to assess for injuries but is not the priority during the seizure itself. Option D, evaluating for evidence of incontinence, is also a secondary concern compared to ensuring the client's airway and breathing are stable. In an educational context, this question highlights the critical importance of prioritizing interventions during a medical emergency like a seizure. Nurses must be prepared to act quickly and decisively to ensure the safety and well-being of their clients, especially when faced with unexpected situations. Understanding the priorities of care during a seizure is crucial knowledge for nurses working in various healthcare settings, including pediatric nursing where seizures can occur.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to take is to continue to monitor the fluid output (Option C). This is the most appropriate response because after a paracentesis, it is essential to monitor the drainage output to assess the client's response to the procedure and to watch for any signs of complications. Option A, palpating for abdominal distention, is not the priority in this situation as monitoring fluid output takes precedence to ensure proper drainage and assess for complications. Option B, sending the fluid to the lab for analysis, may be necessary at some point, but the immediate action should be to monitor the fluid output to ensure proper drainage and assess for any immediate concerns. Option D, clamping the drainage tube for 5 minutes, is not recommended as it may lead to a potential buildup of fluid in the abdomen, which could result in discomfort and complications for the client. From an educational standpoint, understanding the importance of monitoring post-procedural drainage output is crucial in pediatric nursing, especially in cases like ascites where fluid removal plays a significant role in managing the client's condition. Nurses must prioritize ongoing assessment and monitoring to ensure optimal patient outcomes and prevent potential complications.

Correct Answer: B

Rationale: In this scenario, option B, Carotid bruit, is the correct answer indicating a client at risk for a brain attack (stroke). A carotid bruit is an abnormal sound heard when auscultating the carotid artery, which can indicate turbulent blood flow due to atherosclerosis, a major risk factor for stroke. This finding is significant because it suggests potential narrowing or blockage of the carotid artery, increasing the risk of emboli formation and subsequent stroke. Option A, nuchal rigidity, is associated with meningitis, not specifically with an increased risk for stroke. Option C, jugular vein distention, is more related to cardiovascular conditions like heart failure, not a direct indicator of stroke risk. Option D, palpable cervical lymph node, is more indicative of a localized infection or inflammation, not directly linked to stroke risk assessment. In an educational context, understanding these assessment findings and their significance in differentiating between various health conditions is crucial for pediatric nurses caring for patients with cardiovascular disorders. Being able to recognize these signs accurately can lead to timely interventions and prevention strategies, ultimately improving patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) Invite friends over regularly to share in meal times. This option is the best choice because it addresses a potential psychosocial factor contributing to the weight loss of the client with Parkinson's disease. Parkinson's disease can lead to social isolation, depression, and decreased appetite, which can all contribute to weight loss. By inviting friends over for meals, the client is more likely to have social interaction, which can improve mood and appetite. Option B) Encouraging the client to drink clear liquids between meals does not directly address the underlying issue of weight loss in Parkinson's disease. While hydration is important, it does not specifically target the potential causes of weight loss in this case. Option C) Coaching the client to make an intentional effort to swallow is not the most appropriate response as it assumes the weight loss is solely due to swallowing difficulties, which may not be the case for this client. Option D) Talking to the healthcare provider about prescribing an appetite stimulant should be considered if other interventions do not work; however, it should not be the first line of action. Encouraging social interaction and a supportive environment during meals can be more effective in addressing weight loss in this situation. In an educational context, understanding the multifactorial nature of weight loss in clients with Parkinson's disease is crucial for nurses caring for these individuals. Providing holistic care that addresses not only physical symptoms but also psychosocial aspects can lead to better outcomes for the client.

Correct Answer: C

Rationale: In the scenario of a client with a liver abscess undergoing surgical evacuation and drainage, the most important laboratory value for the nurse to monitor following the procedure is the white blood cell count (WBC). Rationale for selecting white blood cell count (WBC): 1. Infections, such as a liver abscess, trigger an inflammatory response leading to an increase in WBC count, specifically neutrophils. Monitoring the WBC count post-surgery helps assess the body's response to the infection and the effectiveness of treatment. Reasons for eliminating other options: A) Serum creatinine: While important for assessing kidney function, it is not directly related to monitoring for post-surgical complications of a liver abscess. B) Blood urea nitrogen (BUN): Primarily indicates kidney function and hydration status, not the immediate concern post-surgical drainage of a liver abscess. D) Serum glucose: Monitoring glucose levels is crucial in diabetic patients or those at risk of hypoglycemia, but it is not the priority in this scenario. Educational context: Understanding the rationale behind monitoring specific laboratory values post-surgery is crucial for nurses caring for pediatric patients with cardiovascular disorders. This knowledge ensures timely identification of complications, appropriate interventions, and improved patient outcomes. Regular assessment and interpretation of laboratory values are essential skills for pediatric nurses to provide safe and effective care.