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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Ensure the child is placed on droplet precautions is the priority because bacterial meningitis is highly contagious. Droplet precautions help prevent the spread of the infection to others in the hospital.
B. Encouraging the child to drink plenty of fluids is not the priority in the acute phase of meningitis, as increased fluid intake may not be appropriate, especially if there is elevated intracranial pressure or vomiting. Fluid management should be carefully monitored by the healthcare team.
C. Administering intravenous antibiotics is crucial because bacterial meningitis requires prompt treatment with antibiotics to prevent complications and reduce mortality.
D. Providing comfort measures such as dimming the lights is important because the child may be sensitive to light, noise, and stimuli. A calm, quiet environment can help reduce discomfort and manage symptoms like headache and photophobia.
E. Preparing the child for a CT scan of the head might be indicated if there are signs of increased intracranial pressure, but it is not the immediate priority. Initial treatment with antibiotics and managing the environment are higher priorities.
Correct Answer is ["B","D","E"]
Explanation
A. Sickled red blood cells are flexible, making it easier for these cells to travel through small vessels is incorrect. Sickled red blood cells are rigid and inflexible, which makes it difficult for them to pass through small blood vessels, contributing to blockages and reduced oxygen delivery.
B. Sickled red blood cells are c-shaped and tend to stick together more easily is correct. Sickled red blood cells have an abnormal, crescent or "C" shape, and they stick together, which can cause clumping and block blood flow in small vessels, leading to pain and organ damage.
C. Sickled red blood cells have a long-life span. Therefore, they circulate in the blood longer than healthy cells is incorrect. Sickled red blood cells have a shortened life span (about 10-20 days) compared to normal red blood cells, which typically last 120 days, leading to a higher rate of cell destruction and anemia.
D. Sickled red blood cells are rigid, making it difficult for the cells to travel through smaller vessels is correct. The rigidity of sickled cells prevents them from easily moving through small blood vessels, causing occlusions, pain, and organ damage.
E. Sickled red blood cells have a short life span which decreases the number of red blood cells circulating in the blood is correct. Due to their short life span, sickled cells are destroyed more quickly, leading to anemia and reduced oxygen-carrying capacity in the blood.
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