A child is hospitalized after a serious motor vehicle crash and has developed increased urination. What action by the nurse takes priority?
Restrict dietary sodium intake.
Assess the daily serum sodium level.
Weigh the child daily.
Monitor the child's intake and output.
The Correct Answer is D
In this scenario, the child's increased urination after a serious motor vehicle crash may
indicate a potential issue with fluid balance. Monitoring the child's intake and output is the
priority action for the nurse. This involves accurately measuring and recording the fluids the
child consumes (intake) and the fluids the child eliminates through urine, sweat, and other
sources (output). By closely monitoring the child's intake and output, the nurse can assess the
child's fluid status and identify any abnormalities or imbalances that may require further
intervention.
Restrict dietary sodium intake in (option A) is incorrect because restricting dietary sodium
intake, may be necessary in certain situations, such as if the child has a known sodium
imbalance or hypertension. However, it is not the priority action in this scenario.
Assess the daily serum sodium level in (option B) is incorrect because assessing the daily
serum sodium level, is important to evaluate the child's electrolyte balance. However, it is not
the priority action compared to monitoring the child's intake and output.
Weigh the child daily in (option C) is incorrect because weighing the child daily, is a useful
measure to assess changes in fluid balance. However, it is not the priority action in this
scenario compared to monitoring the child's intake and output, which provides real-time
information on fluid balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A sign of increased intracranial pressure (ICP) in a 10-year-old child is a headache. Headache is a common symptom associated with increased pressure within the cranial cavity. It can be a result of various conditions that cause elevated intracranial pressure, such as brain tumours, intracranial haemorrhage, hydrocephalus, or brain trauma. The headache may be described as persistent, worsening, or accompanied by other symptoms such as nausea, vomiting, or changes in neurological status.
tachypnoea (rapid breathing), in (option A) is incorrect because it is not a specific sign of increased intracranial pressure. It can be seen in various conditions, including respiratory and cardiovascular disorders, anxiety, or physical exertion.
bulging fontanel in (option B) is incorrect because it, is more commonly observed in infants and is not typically seen in older children. The fontanelles (soft spots) on an infant's skull normally close by the age of 18-24 months.
an increase in head circumference in (option D) is incorrect because it, may be a sign of increased intracranial pressure in infants. However, in a 10-year-old child, the fontanelles are typically closed, and head circumference growth is not a reliable indicator of increased intracranial pressure
Correct Answer is A
Explanation
Graves' disease is an autoimmune disorder that affects the thyroid gland and results in the overproduction of thyroid hormones. Treatment for Graves' disease typically involves medications to regulate thyroid function. Adherence to the medication regimen is crucial for managing the disease and controlling symptoms.
By prioritizing the goal of verbalizing the importance of adherence to the medication regimen, the nurse aims to educate the adolescent about the significance of taking medications as prescribed. This education can help the adolescent understand the impact of medication non-adherence on their health and encourage them to actively participate in their treatment.
, developing alternative educational goals in (option B) is incorrect because it, is not directly related to the management of Graves' disease and its treatment.
allowing the adolescent to make decisions about whether or not to take medication in (option C) is incorrect because it, is not appropriate for a condition like Graves' disease where medication adherence is necessary for disease management. In this case, the nurse should focus on providing education and support to help the adolescent understand the importance of medication compliance.
relieving constipation in (option D) is incorrect because it, may be a consideration if constipation is a symptom experienced by the adolescent with Graves' disease. However, it is not the priority nursing goal as compared to ensuring adherence to the medication regimen, which directly addresses the management of Graves' disease.
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