A nurse is caring for a 13-year-old adolescent in the pediatric emergency room who has a suspected head injury. Which of the following actions should the nurse take first?
Notify the adolescent's primary care provider.
Collect a detailed past medical history.
Perform a thorough assessment noting acute conditions
Administer pain medication to the adolescent.
The Correct Answer is C
A. Notify the adolescent's primary care provider is incorrect. While it is important to notify the healthcare provider, the immediate priority is performing a thorough assessment to determine the severity of the head injury and any potential complications, such as changes in consciousness or neurological status.
B. Collect a detailed past medical history is incorrect. Although collecting medical history is important, it is not the priority in the acute phase of a suspected head injury. The priority is to assess the current condition of the adolescent, especially signs of deterioration.
C. Perform a thorough assessment noting acute conditions is correct. The priority in suspected head injuries is to perform a thorough assessment to evaluate the patient's neurological status. This includes checking for signs of a concussion, increased intracranial pressure, or any other acute conditions that may require immediate intervention.
D. Administer pain medication to the adolescent is incorrect. Pain management is important, but it should not be the first action when a head injury is suspected, as it can mask symptoms or affect the ability to assess neurological function properly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1"]
Explanation
Total daily dose: 1.5 mg
Divided into 3 equal doses: 1.5 mg / 3 = 0.5 mg per dose
Now, we can calculate the number of tablets:
Number of tablets = Desired dose (mg) / Tablet strength (mg/tablet)
Number of tablets = 0.5 mg / 0.5 mg/tablet = 1 tablet
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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