A 5-year-old child is recovering after undergoing surgery for a brain tumor. The nurse is reviewing the child's postoperative care plan. The child is alert, but the nurse notices that the child is vomiting and complaining of a headache. The nurse's priority action should be:
Encourage the child to drink fluids to stay hydrated
Position the child in a flat supine position to prevent increased intracranial pressure (ICP)
Administer an antiemetic to control vomiting
Assess the child's neurological status and check for signs of increased intracranial pressure
The Correct Answer is D
A. Encouraging the child to drink fluids to stay hydrated is incorrect because while hydration is important, the priority is identifying and managing potential increased intracranial pressure (ICP). Giving fluids before assessing neurological status may delay recognition of a serious complication.
B. Positioning the child in a flat supine position is incorrect because a flat supine position can actually increase ICP. Postoperative positioning for brain surgery typically involves head elevation (30 degrees) to promote venous drainage and reduce ICP, unless contraindicated.
C. Administering an antiemetic to control vomiting is incorrect as controlling vomiting is secondary. Vomiting can be a sign of increased ICP, so addressing the underlying cause is more important than treating symptoms alone.
D. Assessing the child's neurological status and checking for signs of increased intracranial pressure is correct. Vomiting and headache after brain surgery are red flags for increased ICP, which can lead to life-threatening complications such as brain herniation. Priority nursing actions include frequent neurological assessments (level of consciousness, pupil size and reactivity, motor function), monitoring vital signs for changes in blood pressure, pulse, and respiration (Cushing’s triad), notifying the healthcare provider immediately if ICP is suspected, and implementing interventions to reduce ICP, such as proper positioning, oxygenation, and minimizing stimuli.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Small amounts of alcohol are safe during the second trimester." is incorrect because no amount of alcohol is considered safe during pregnancy. Even small amounts can affect fetal development and increase the risk of fetal alcohol spectrum disorders (FASD).
B. "Alcohol is only harmful in the first trimester." is incorrect because alcohol exposure can be harmful at any stage of pregnancy, not just the first trimester. While organogenesis occurs early, alcohol can still affect fetal growth, brain development, and neurobehavioral outcomes throughout pregnancy.
C. "Alcohol should be avoided completely during pregnancy." is correct. The safest recommendation is complete abstinence from alcohol. This approach eliminates the risk of alcohol-related complications and supports optimal fetal development. Health authorities, including the CDC and ACOG, advise that no level of alcohol is safe during pregnancy.
D. "Beer is safer than hard liquor while pregnant." is incorrect because all types of alcoholic beverages pose a risk to the developing fetus, regardless of alcohol content or type. There is no safe form of alcohol during pregnancy.
Correct Answer is B
Explanation
A. Cataract is incorrect because although cataracts can cause a cloudy or white appearance of the lens, they are less commonly associated with leukocoria (white pupillary reflex) seen in photographs and are not typically linked with intermittent eye crossing in toddlers.
B. Retinoblastoma is correct because leukocoria (white reflection in the pupil) is the classic and most common presenting sign of this malignant eye tumor in young children. Strabismus or eye crossing often occurs because the tumor interferes with normal vision. Retinoblastoma is a medical emergency, and early detection is critical to preserve vision and life.
C. Strabismus is incorrect because while it involves misalignment of the eyes, it does not cause a white pupillary reflex. Strabismus may be a symptom of an underlying condition, such as retinoblastoma, but it is not the primary diagnosis given these findings.
D. Glaucoma is incorrect because pediatric glaucoma typically presents with tearing, photophobia, corneal cloudiness, and enlarged eyes, not leukocoria. Eye crossing is also not a primary feature of glaucoma.
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