A two-year-old arrives in the emergency room with an elevated temperature. During the physical examination, the child's colour becomes dusky, the body stiffens and the extremities begin to twitch. The nurse should be aware that the child is most probably experiencing?

1. A

   Febrile seizures

2. B

   Respiratory arrest

3. C

   A temper tantrum

4. D

   Shivering

Appeared in: AIIMS Bhatinda NO - 2019

Explanation

• The clinical presentation of a high fever in a two-year-old followed by sudden body stiffening (tonic phase), twitching of extremities (clonic phase), and a dusky skin color (transient apnea) is the hallmark of a febrile seizure.
• Febrile seizures are convulsions in a child that may be caused by a spike in body temperature, often from an infection.
• They typically occur in children between the ages of 6 months and 5 years.
• The seizure itself is usually harmless and ends on its own within a few minutes, though it is frightening for parents.

Why Other Options Were Wrong

• Option B: Respiratory arrest is the cessation of breathing. While it would cause a dusky or cyanotic color, it is not primarily characterized by body stiffening and twitching convulsions.
• Option C: A temper tantrum is a behavioral outburst and is a voluntary action. It does not involve involuntary physiological changes like generalized body stiffening, convulsive twitching, or a dusky skin color.
• Option D: Shivering is the body's attempt to generate heat and consists of fine, rapid muscle tremors. It does not involve the organized, forceful tonic-clonic movements or the change in consciousness and skin color seen in a seizure.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Recognition of signs and symptoms of a febrile seizure in a pediatric patient in acute care settings.
• Recognizing a febrile seizure is a critical nursing skill in pediatric emergency care. The immediate priority is patient safety—preventing injury and ensuring a patent airway.
• A key nursing role is to provide reassurance and education to the parents, who are often terrified. Explaining that simple febrile seizures are common and typically do not cause brain damage is crucial.
• What if? If the seizure lasts for more than 5 minutes (status epilepticus), it becomes a medical emergency. The nurse's role would shift to administering rescue medications (e.g., rectal diazepam or intranasal midazolam) as per protocol and preparing for advanced airway management.

How to Approach the Question

• First, identify the key elements of the clinical scenario: a 2-year-old patient, a high fever, and acute neurological changes.
• Analyze the specific signs described: 'dusky' color, 'body stiffens,' and 'extremities begin to twitch.'
• Recognize this combination of signs as the classic tonic-clonic pattern of a seizure.
• Correlate the seizure activity with the presence of a high fever in a young child, which points directly to a febrile seizure.
• Evaluate the other options. Respiratory arrest lacks the seizure movements. A temper tantrum is behavioral. Shivering is a different type of muscle activity.
• Select the option that best fits the complete clinical picture.

Concept Tested & Keywords

• Concept Tested: Recognition of signs and symptoms of a febrile seizure in a pediatric patient.
• Stem keywords: two-year-old, elevated temperature, dusky, body stiffens, extremities twitch
• Lead-in keywords: most probably experiencing
• Clinical cues: Age of 2 years falls within the typical range for febrile seizures (6 months to 5 years).
• Clinical cues: The sequence of events (fever followed by seizure activity) is characteristic.

Question ID

QBCy55uuouu2jLcva_zYod

Copy ID

Reference Book

E6 Nelson Textbook of Pediatrics(2024) — Volume 1 pp. 593-595, 1643-1645

E6 Nursing Fundamentals Potter Perry 12e Part 3 p. 11-13