A nurse at an urgent care clinic is caring for a child who hit her head on the playground at school 30 minutes ago. Which of the following findings is the nurse's priority?
2 cm (0.8 in) scalp laceration.
Nasal discharge negative for glucose.
Asymmetric pupils.
Negative Babinski reflex.
The Correct Answer is C
Choice A rationale:
A 2 cm scalp laceration, while a concern, is not the nurse's priority in this scenario. The child's head injury could potentially be serious, but priority should be given to neurological assessments and signs of increased intracranial pressure.
Choice B rationale:
Nasal discharge negative for glucose is not indicative of a major issue in this context. While cerebrospinal fluid (CSF) leaking from the nose after head trauma is a concern, it is not mentioned in this scenario, and this choice does not take precedence over other neurological signs.
Choice C rationale:
This is the correct answer. Asymmetric pupils can be a sign of a serious neurological issue, such as a brain injury or increased intracranial pressure. It requires immediate attention and further evaluation to assess the child's neurological status and determine the extent of the injury.
Choice D rationale:
A negative Babinski reflex is a normal finding in this context and does not require immediate priority attention. The Babinski reflex is typically present in infants and disappears as the child grows older. Its absence is expected in older children and adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Lethargy, or extreme fatigue and sluggishness, is a characteristic symptom of hypothyroidism. Hypothyroidism occurs due to an underactive thyroid gland, which leads to a decrease in metabolic activity and energy levels. Children with hypothyroidism often exhibit lethargy, weakness, and a lack of interest in activities. This is due to the reduced metabolic rate and overall slowing down of bodily functions.
Choice B rationale:
Diarrhea is not a common finding associated with hypothyroidism. In fact, hypothyroidism tends to slow down gastrointestinal motility, leading to constipation rather than diarrhea. Therefore, diarrhea is not expected as a symptom in a child with hypothyroidism.
Choice C rationale:
Tachycardia, an elevated heart rate, is not typically associated with hypothyroidism. Instead, hypothyroidism often leads to bradycardia (a slower-than-normal heart rate) due to the overall slowing of the body's metabolic processes.
Choice D rationale:
Hirsutism, which refers to excessive hair growth in areas where hair growth is typically seen in males, is not a common finding in hypothyroidism. Hirsutism is more commonly associated with hormonal imbalances such as polycystic ovary syndrome (PCOS) rather than hypothyroidism.
Correct Answer is A
Explanation
The answer is a. Hard-boiled egg.
Hard-boiled eggs are a safe snack for a toddler.They are soft, easy to chew, and rich in nutrients.
Now, let’s discuss why the other options are not recommended:
b. Grapes: Whole grapes are not recommended for toddlers due to the risk of choking.They are round and slippery, making them difficult for toddlers to chew properly.
c. Raw carrots: Similar to grapes, raw carrots pose a choking hazard for toddlers.They are hard and can break into large pieces that might block a toddler’s airway.
d. Popcorn: Popcorn is not safe for toddlers. The kernels can get stuck in a toddler’s throat and cause choking.Moreover, unpopped or partially popped kernels are hard and can also pose a choking risk.
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