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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Exploring why the mother wants to hold the baby is important, but it does not directly address her immediate desire to hold her baby. Delaying the action could lead to emotional distress for the mother.
Choice B rationale:
Showing the mother how to lightly rub the baby's back above the suture line might be appropriate, but it doesn't fulfill the mother's wish to hold her baby. It also doesn't fully consider the sensitivity of the surgical site.
Choice C rationale:
Helping the mother hold the baby without placing pressure on the suture line is the most appropriate action. It addresses the mother's emotional needs while also considering the infant's post-operative condition.
Choice D rationale:
Reassuring the mother that she will be able to hold her baby in four to five days does not provide immediate comfort and support for her emotional distress. It's important to address her needs in the present moment.
Correct Answer is B
Explanation
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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