A 15-year-old patient with a closed head injury is admitted to the pediatric intensive care unit and is intubated. The nurse should monitor the patient for which symptom?

Neck vein distention.

Fixed, dilated pupils.

Shortness of breath.

Glycosuria.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Neck vein distention might be seen in conditions affecting venous return to the heart, such as heart failure, but it's not a specific symptom of closed head injury.

Choice B rationale:

Fixed, dilated pupils are a classic sign of increased intracranial pressure. The pressure can compress the cranial nerves, leading to changes in pupillary size and reactivity.

Choice C rationale:

Shortness of breath is more related to respiratory issues and might not be directly linked to a closed head injury.

Choice D rationale:

Glycosuria, the presence of glucose in the urine, is not a primary symptom of closed head injury. It could be related to diabetes or other metabolic conditions.

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Correct Answer is B

Explanation

Choice A rationale:

Returning to the hospital if the child spits up blood is a correct response as it indicates the recognition of potential postoperative bleeding.

Choice B rationale:

Giving the child cherry gelatin, even though it's the child's favorite, might not be appropriate after a tonsillectomy/adenoidectomy, as certain foods can irritate the healing throat.

Choice C rationale:

Returning to the hospital if the child develops difficulty breathing is a necessary step to address any respiratory distress.

Choice D rationale:

Having the child rinse her mouth frequently with water to prevent a bad breath odor is a suitable suggestion to maintain oral hygiene and comfort after surgery. In all three scenarios, the rationale for the correct answers revolves around patient safety, comfort, and appropriate post-operative care. The incorrect choices in each question either introduce potential complications, misunderstandings, or actions that might compromise the patient's well-being.

A. Ribbon-like stools. B. Distended abdomen. C. Chronic constipation. D. Black and tarry stools.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale:

Ribbon-like stools are a classic sign of Hirschsprung's disease, indicating narrowed or obstructed bowel segments due to the absence of ganglion cells in the intestine's muscular layers.

Choice B rationale:

A distended abdomen is common in Hirschsprung's disease due to the accumulation of stool and gas in the narrowed segments of the intestine.

Choice C rationale:

Chronic constipation is a result of the dysfunctional intestinal motility caused by Hirschsprung's disease. The absence of ganglion cells leads to a lack of peristalsis and difficulty passing stools.

Choice D rationale:

Black and tarry stools are indicative of upper gastrointestinal bleeding, often caused by conditions like peptic ulcers. This finding is not directly related to Hirschsprung's disease.

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A 15-year-old patient with a closed head injury is admitted to the pediatric intensive care unit and is intubated. The nurse should monitor the patient for which symptom?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions to the parent of a patient who had a tonsillectomy/adenoidectomy. Which statement would indicate that the parent needs further teaching?

Correct Answer is B

Explanation

A child has been diagnosed with Hirschsprung's disease. Which of the following findings would the nurse expect the parents to report in the child's history? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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