A nurse is caring for a child who has been diagnosed with a concussion. Which of the following findings should the nurse identify as causing this type of injury?
A deep wound that caused external bleeding on the head and face
Trauma from contact sports that caused the brain to twist or bounce against the skull
A blow to the head that caused diffuse bleeding between the skull and brain
A fall that caused blood from a ruptured artery to pool in the brain
The Correct Answer is B
A. A deep wound causing external bleeding does not describe a concussion, which involves a brain injury due to trauma, not a superficial wound.
B. A concussion is a mild traumatic brain injury caused by a blow to the head or trauma that causes the brain to twist or bounce inside the skull. This movement can lead to temporary neurological impairment.
C. Bleeding between the skull and brain (epidural hematoma or subdural hematoma) is associated with more severe traumatic brain injuries, not a concussion.
D. A ruptured artery leading to pooling of blood in the brain is more characteristic of an intracerebral hemorrhage or a severe head injury, not a concussion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Neurological assessment is critical in identifying potential complications, especially in cases of head injury, infection, or brain-related conditions. A change in mental status or neurological findings (e.g., confusion, loss of consciousness) warrants immediate follow-up.
B. Basic metabolic panel provides key information on electrolyte imbalances, kidney function, and acid-base status. Imbalances or abnormalities, such as hyperkalemia or hyponatremia, can indicate life-threatening conditions.
C. Blood pressure/heart rate is crucial to monitor because abnormalities in these vital signs can indicate cardiovascular instability, shock, or autonomic dysfunction. Significant changes require immediate intervention.
D. Abdominal assessment is important but not always immediately urgent unless signs of acute abdominal issues (e.g., severe pain, distention, or bleeding) are present.
E. Complete blood count is essential for monitoring for signs of infection, anemia, or bleeding disorders. Abnormalities such as low hemoglobin or a high white blood cell count require further investigation.
F. Pain assessment is important but may not always indicate an immediate life-threatening issue. However, uncontrolled pain or new-onset severe pain can signal a complication, such as infection or tissue damage, which needs prompt attention.
Correct Answer is C
Explanation
A. Gross motor skill development is important for an infant’s overall development, but it is not the primary focus when caring for an infant with a cleft palate. Gross motor skills typically develop at a normal rate unless there are additional concerns.
B. Fine motor skill development is also important, but for an infant with a cleft palate, the primary concern is related to communication and feeding difficulties. Fine motor development generally follows the same trajectory unless there are complicating factors.
C. Speech and language acquisition is the most important area to focus on when planning care for an infant with a cleft palate. A cleft palate can significantly impact the infant’s ability to produce sounds and develop normal speech patterns. Early intervention and support from speech therapists are essential to address these issues.
D. Cognitive development is vital for all infants, but cleft palate primarily affects speech and feeding, making speech and language acquisition the most immediate concern for overall development.
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