A nurse is caring for a child who has a nosebleed. Which of the following actions should the nurse take?

Have the child sit with her head tilted forward and hold pressure on her nose for 10 min.

Place the child in a sitting position and tilt her head back.

Apply ice at the opening of the nares for 5 min and then re-check for bleeding.

Place the child in a supine position with a pillow under her head.

Answer and Explanation

The Correct Answer is A

A. Have the child sit with her head tilted forward and hold pressure on her nose for 10 min. Tilting the head forward helps prevent blood from flowing down the throat and causing nausea or choking. Applying pressure to the nose for 10 minutes helps to stop the bleeding.
B. Place the child in a sitting position and tilt her head back. Tilted head back can cause blood to flow down the throat and potentially cause aspiration or choking. It's not recommended in managing nosebleeds.
C. Apply ice at the opening of the nares for 5 min and then re-check for bleeding. While cold compresses can help constrict blood vessels, direct pressure and maintaining a forward head position are more effective for stopping nosebleeds.
D. Place the child in a supine position with a pillow under her head. Supine position can cause blood to flow down the throat and is not recommended in managing nosebleeds due to the risk of aspiration.

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Correct Answer is C

Explanation

A. "Give your infant an oral rehydration solution." While rehydration is important, projectile vomiting could indicate a more serious underlying issue that needs medical evaluation.
B. "You might want to try switching to a different formula." Formula intolerance is less likely to cause projectile vomiting. A change in formula should not be suggested without ruling out more serious conditions first.
C. "Bring your infant into the clinic today to be seen." Projectile vomiting in an infant, especially when followed by hunger, can indicate pyloric stenosis, a condition that requires prompt medical evaluation. The infant should be seen by a healthcare provider to determine the cause and initiate appropriate treatment.
D. "Burp your child more frequently during feedings." Burping can help with regular gas and minor feeding issues, but it is unlikely to resolve projectile vomiting.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

Pain: Although pain management is important for comfort and to improve quality of life, in this scenario, the child’s pain is rated as a 3 on the FLACC scale, which is moderate. Immediate pain does not seem to be the primary or most urgent concern compared to the high fever and potential underlying conditions.
Bruising: The presence of bruising in various stages of healing and petechiae suggests a possible underlying hematologic issue or trauma. While concerning and needing further investigation, it does not require immediate intervention compared to the fever.
Heart rate: The heart rate is elevated at 150 beats per minute, which could be a response to the fever, pain, or anxiety. Addressing the fever may help in normalizing the heart rate.

Respiratory rate: The respiratory rate is elevated but not critically so (normal for a toddler is 20-30 breaths per minute). There is no increased work of breathing noted, so while monitoring is important, it is not the most immediate priority compared to the fever and lab abnormalities.

Nasal stuffiness: While nasal congestion can be uncomfortable and contribute to respiratory distress, it is not an immediate threat to the child’s health and can be managed after addressing the fever and the concerning laboratory values.

Petechiae: Petechiae are small red or purple spots that can indicate bleeding under the skin and may be associated with a bleeding disorder or infection. However, the underlying cause might be revealed through laboratory investigations, which are prioritized after managing the fever. Immediate intervention for petechiae alone is not usually required unless there is evidence of significant bleeding or other acute symptoms.

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A nurse is caring for a child who has a nosebleed. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

A nurse is assisting in the care of a toddler. Exhibits A nurse is assisting in the care of a client. Complete the following sentence by using the list of options. The nurse should first address the child's dropdown followed by the child's dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Explanation

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