A nurse is assessing a child who has a suspected head injury. What would be the initial action the nurse should take to assess the child's cognitive status?
Have blood work done
Monitor intracranial pressure
Recommend a CT scan
Use the Glasgow cognitive scale
The Correct Answer is D
A. Have blood work done is not the initial priority for assessing cognitive status in a child with a suspected head injury. Blood work may be ordered later to assess for any contributing factors but is not the first step in cognitive assessment.
B. Monitor intracranial pressure is important but typically comes after an initial cognitive assessment. Elevated intracranial pressure may be suspected after assessing cognitive function and other neurological signs.
C. Recommend a CT scan might be ordered by a healthcare provider to assess for structural brain damage, but the initial assessment of cognitive status should be done first to evaluate the severity of the injury.
D. Use the Glasgow cognitive scale is the correct initial action. The Glasgow Coma Scale (GCS) is used to assess a child's level of consciousness and cognitive function following a head injury. It helps determine the severity of the injury and guides further intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Laxatives are not typically used for sickle cell crisis unless the client is experiencing constipation, which is unrelated to the crisis itself.
B. Thyroid replacement medications are used for hypothyroidism and would not be a first-line treatment for sickle cell crisis.
C. Diuretics may be used in conditions like heart failure or kidney disease, but they are not indicated for sickle cell crisis and may worsen dehydration.
D. Pain medications are the correct intervention during a sickle cell crisis. The crisis involves severe pain due to the sickling of red blood cells blocking blood flow to tissues. Opioids like morphine and hydromorphone are commonly administered to manage the severe pain.
Correct Answer is C
Explanation
A. Increased temperature, tachycardia, tachypnea is not consistent with Cushing's triad. These signs generally reflect an infection, fever, or a stress response, and are not indicative of increased intracranial pressure (ICP) or brain herniation.
B. Decreased temperature, bradycardia, bradypnea is incorrect. While bradycardia is a component of Cushing's triad, decreased temperature and bradypnea are not part of this syndrome. The signs of Cushing's triad typically include increased blood pressure, not decreased temperature.
C. Bradycardia, high blood pressure, irregular respirations is correct. These are the hallmark signs of Cushing's triad, which indicate a significant increase in intracranial pressure. Bradycardia occurs as a result of elevated pressure on the brainstem, high blood pressure develops as a compensatory mechanism to maintain perfusion, and irregular respirations reflect brainstem dysfunction.
D. Bradycardia, hypotension, tachypnea is incorrect. Hypotension is not part of Cushing's triad. Instead, high blood pressure is typically present in this condition due to the body's compensatory response to increased ICP.
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