A 3-year-old patient who is admitted to the hospital for the treatment of a skull fracture has clear liquid draining from his nose. In consideration of the patient's injury, which action should the nurse take initially?

Give the patient a soft tissue to clean up the drainage.

Check the drainage for glucose content.

Obtain a specimen of the drainage for culture and sensitivity.

Ask the father if the patient had nasal drainage before his injury.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Giving the patient a soft tissue is not the initial action to take when dealing with clear liquid drainage from the nose. Assessing the content of the drainage is more crucial for appropriate management.

Choice B rationale:

Checking the drainage for glucose content is essential because the presence of glucose indicates that the drainage is cerebrospinal fluid (CSF), which can occur with a skull fracture that involves the base of the skull.

Choice C rationale:

Obtaining a specimen of the drainage for culture and sensitivity is important, but it is not the initial action. Confirming the nature of the drainage takes precedence.

Choice D rationale:

Asking the father about nasal drainage before the injury is not as relevant as assessing the current drainage, which could be indicative of a CSF leak.

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Correct Answer is A

Explanation

Choice A rationale:

Allowing the child to have the soiled stuffed dog within sight but out of reach respects his attachment to the comfort object while maintaining hygiene standards of the hospital environment. The child's emotional well-being is crucial, and separation from a beloved item during a hospital stay can be distressing. Placing the dog in view but inaccessible helps strike a balance between comfort and infection control.

Choice B rationale:

While the mother's desire to keep the dog with the child is understandable, infection control is a concern in a hospital setting. Allowing the soiled object to remain in close proximity could compromise the child's health.

Choice C rationale:

Suggesting that the mother take the dog home to wash it and bring it back later might cause unnecessary distress for the child, who may worry about being separated from the comfort object for an extended period.

Choice D rationale:

Choosing a replacement from the playroom's stuffed animals could be unsettling for the child, as his attachment is to his specific dog. The familiarity of his own toy is likely to provide more comfort during the hospitalization. .

A. Pedal edema. B. Cardiac arrhythmias. C. Circumoral cyanosis. D. Infrequent voiding.

Correct Answer is B

Explanation

Choice A rationale:

Pedal edema is not indicative of digoxin toxicity. Digoxin toxicity primarily affects the heart's electrical activity and rhythm, not fluid accumulation in the extremities.

Choice B rationale:

Cardiac arrhythmias are a hallmark sign of digoxin toxicity. Digoxin can lead to various types of arrhythmias, such as atrial tachycardia, atrial fibrillation, and ventricular ectopy. This occurs due to the drug's effects on altering the electrical conduction in the heart.

Choice C rationale:

Circumoral cyanosis is not a typical sign of digoxin toxicity. This symptom might be seen in conditions like methemoglobinemia or respiratory distress, but it's not directly related to digoxin toxicity.

Choice D rationale:

Infrequent voiding is not a specific sign of digoxin toxicity. It could be related to various factors, such as fluid intake, renal function, or underlying medical conditions, but it's not a hallmark of digoxin toxicity.

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A 3-year-old patient who is admitted to the hospital for the treatment of a skull fracture has clear liquid draining from his nose. In consideration of the patient's injury, which action should the nurse take initially?

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Naxlex Comprehensive Predictor Exams

A 4-year-old patient with cystic fibrosis is hospitalized with an acute pulmonary exacerbation. When the patient is admitted, he is clutching a soiled, tattered, stuffed dog. His mother says, "He insisted on bringing the dog with him. It really is filthy.". Which nursing action is most appropriate?

Correct Answer is A

Explanation

The nurse is caring for a pediatric patient receiving digoxin therapy. Which assessment finding would indicate digoxin toxicity?

Correct Answer is B

Explanation

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