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. "We will return to the hospital if my child spits up blood.". B. "I'll give my child cherry gelatin since that is her favorite.". C. "We will return to the hospital if my child develops difficulty breathing.". D. "I'll have my child rinse her mouth frequently with water to prevent a bad breath odor.".

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.

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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?

Nursing Test Bank

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 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

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