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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Crushing iron supplements and mixing them with applesauce may make the medication easier to take, but it does not directly improve absorption. In fact, crushing tablets could alter the formulation and absorption, especially if the iron supplement is enteric-coated.

B. Administering iron with a glass of milk can actually inhibit absorption because calcium, which is found in milk, can interfere with the absorption of iron.

C. While tarry green stools are a common side effect of iron supplements, this is not a reason to discontinue the medication unless instructed by the healthcare provider.

D. This is the correct answer. Vitamin C enhances the absorption of iron. Administering the supplement with a vitamin C-rich drink, such as orange juice, helps maximize iron absorption from the gastrointestinal tract.

A. An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin. B. An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin. C. An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin. D. An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin.

Correct Answer is C

Explanation

A. An inguinal hernia occurs when digestive fluids leak from the bowel, causing swelling that results in a bulge in the groin is incorrect. An inguinal hernia involves a protrusion of bowel or fatty tissue through a weakness in the abdominal wall, not digestive fluids leaking from the bowel.

B. An inguinal hernia occurs when a viral infection weakens the intestine, allowing the bowel to herniate into the groin is incorrect. Inguinal hernias are congenital or result from increased intra-abdominal pressure, not caused by viral infections.

C. An inguinal hernia occurs when a part of the bowel or fatty tissue slips through a weak spot in the abdominal cavity near the groin is correct. Inguinal hernias occur when tissue, usually part of the intestine or fatty tissue, pushes through a weak area in the abdominal wall near the groin. This condition is common in infants and children.

D. An inguinal hernia occurs when an accumulation of excess gas in the abdominal cavity results in a bulge in the groin is incorrect. While excess gas can cause bloating or discomfort, it is not responsible for the development of an inguinal hernia. The bulge is caused by the protrusion of tissue through a weakness in the abdominal wall.

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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?

Nursing Test Bank

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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?