A nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury.
Which of the following actions should the nurse take first?
Assess respiratory status.
Inspect for fluid leaking from the ears.
Examine the scalp for lacerations.
Check pupil reactions.
The Correct Answer is A
The first action the nurse should take is to assess the respiratory status of the infant.
After a head injury, it is important to ensure that the child’s airway is clear and that they are breathing adequately.
This is a crucial step in providing care for a patient with a head injury.
Choice B is wrong because inspecting for fluid leaking from the ears is not the first priority.
Choice C is wrong because examining the scalp for lacerations is not the first priority.
Choice D is wrong because checking pupil reactions is not the first priority.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This statement provides the child with factual information about the purpose of the medication and why it is important for them to take it.
Choice A is wrong because it may not be true that the medication tastes like candy and could lead to mistrust.
Choice B is wrong because it does not address the urgency of taking a stat dose of medication.
Choice D is wrong because it does not provide any information about the purpose of the medication and may not be relevant to the child’s feelings.
Correct Answer is A
Explanation
Following the child’s home sleep routine can help reduce anxiety and promote adequate sleep.
Children thrive on routine and consistency, and maintaining their usual sleep routine can provide a sense of familiarity and comfort in an unfamiliar environment.
Choice B is wrong because leaving the lights on can disrupt the child’s sleep.
Choice C is wrong because allowing the child to adjust their bedtime may disrupt their sleep routine and lead to inadequate sleep.
Choice D is a good option, but following the child’s home sleep routine is the best way to promote adequate sleep.
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