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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Evaluate their readiness to learn.
Choice A rationale:
Limiting the session to 40 minutes might not be the initial step, as it doesn't assess the patient and mother's readiness to learn. Teaching sessions should be tailored to their learning capacity, and time restrictions should come after assessing their readiness.
Choice B rationale:
Having them handle equipment is a valuable step in teaching, but it doesn't address the foundational aspect of assessing their readiness to learn. Jumping straight into equipment handling might not be effective if they are not prepared to absorb the information.
Choice C rationale:
Giving an illustrated book might engage visual learners, but without evaluating their readiness, this approach might not be the most effective starting point. Readiness assessment helps tailor teaching methods to their learning styles and capacities.
Choice D rationale:
Evaluating their readiness to learn is the best initial action. Assessing their understanding, motivation, and any barriers to learning allows the nurse to create a customized teaching plan. This approach enhances the effectiveness of subsequent teaching strategies.
Correct Answer is B
Explanation
Choice A rationale:
Adding medication to orange juice is not recommended for digoxin administration. This can affect the drug's absorption and potency due to interactions with food components.
Choice B rationale:
Ensuring the child has had food or drink before giving the medication is crucial for digoxin administration. Food in the stomach can help mitigate gastrointestinal irritation and enhance drug absorption.
Choice C rationale:
A pulse over forty is too low for digoxin administration. The typical guideline is usually a pulse rate over 60 in pediatric patients before administering digoxin.
Choice D rationale:
Using a calibrated dropper for medication administration is not the standard method for digoxin. Precision in dosing is essential for this drug, and using a calibrated oral syringe or dropper is recommended to accurately measure the dose.
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