A 5-year-old child falls from a tree and loses consciousness briefly. The child wakes up but appears drowsy and confused. What is the priority action by the nurse?

Apply a cold compress to the head

Administer pain medication

Monitor closely for signs of worsening condition

Transport the child to the emergency department immediately

Answer and Explanation

The Correct Answer is D

A. Applying a cold compress can provide comfort but is not the priority action for a child with head trauma and altered mental status.

B. Administering pain medication is not the priority; the child needs a thorough evaluation and possible imaging studies to assess for head injury.

C. Monitoring closely is important, but with the history of head trauma, immediate medical evaluation is crucial to rule out any serious injury.

D. Transporting the child to the emergency department immediately is the priority to ensure proper assessment and management of head trauma.

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Correct Answer is A

Explanation

A. Administering rescue breaths and chest compressions is the immediate action for an unconscious child found after a near-drowning incident. CPR should be initiated immediately.

B. Placing the child in the recovery position is not appropriate for an unconscious child requiring CPR.

C. Initiating abdominal thrusts is used for foreign body airway obstruction, not for an unconscious child found after a near-drowning incident.

D. Administering a sedative is not the appropriate intervention for an unconscious child and can further depress respiratory function.

A. Administering rescue breaths B. Checking for a pulse C. Initiating chest compressions D. Initiating abdominal thrusts

Correct Answer is A

Explanation

A. Administering rescue breaths is the immediate action for an unconscious child who is not breathing. CPR should be initiated immediately.

B. Checking for a pulse can be done after initiating rescue breaths and chest compressions.

C. Initiating chest compressions is part of CPR but should be preceded by rescue breaths.

D. Initiating abdominal thrusts is used for foreign body airway obstruction, not for an unconscious child with a head injury and respiratory distress.

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A 5-year-old child falls from a tree and loses consciousness briefly. The child wakes up but appears drowsy and confused. What is the priority action by the nurse?

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Naxlex Comprehensive Predictor Exams

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