A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline.
Which of the following findings should the nurse expect?
Pinpoint pupils
Hypothermia
Ataxia
Hyperactive reflexes
The Correct Answer is C
Choice A rationale
Pinpoint pupils are not a typical finding in an adolescent who has inhaled gasoline. Pinpoint pupils are more commonly associated with opioid use.
Choice B rationale
Hypothermia is not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Choice C rationale
Ataxia, or lack of muscle coordination, can occur after inhaling gasoline. The gasoline vapors can depress the central nervous system, leading to symptoms such as dizziness, confusion, and ataxia.
Choice D rationale
Hyperactive reflexes are not a typical finding in an adolescent who has inhaled gasoline. Inhalation of gasoline can cause central nervous system depression, leading to symptoms such as dizziness, confusion, and ataxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
The correct answer is choice a. Discourage the child from coughing.
Choice A rationale:
Discouraging the child from coughing is important because coughing can dislodge clots and cause bleeding at the surgical site, which is a common complication after a tonsillectomy.
Choice B rationale:
Providing cranberry juice to the child is not recommended because acidic juices can irritate the throat and cause discomfort or pain.
Choice C rationale:
Maintaining the child in a supine position is not ideal as it can increase the risk of aspiration. Instead, the child should be positioned on their side or with the head elevated to facilitate drainage and reduce the risk of aspiration.
Choice D rationale:
Administering an analgesic to the child on a scheduled basis is important for pain management, but it is not the most immediate action to take one hour postoperatively. Pain management should be part of the overall care plan.
Correct Answer is ["A","C"]
Explanation
he correct answer is Choice A, Choice C.
Choice A rationale: Keeping the child away from others until all vesicles have crusted over is essential to prevent the spread of varicella. The child is no longer contagious once the vesicles have crusted, reducing the risk of transmission.
Choice B rationale: Dressing the child in warm clothing is not recommended as it can cause discomfort and aggravate itching. Loose, comfortable clothing should be used to prevent irritation of vesicles and promote healing.
Choice C rationale: Applying calamine lotion to vesicles on the child’s skin can soothe itching and provide relief. It is a safe and effective topical treatment to manage symptoms associated with varicella, ensuring the child remains comfortable.
Choice D rationale: Bathing the child is recommended to maintain hygiene and prevent secondary infections. Using mild soap and lukewarm water can help keep the skin clean and reduce itching, contrary to avoiding baths.
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