A nurse is caring for a child who is in a halo vest for cervical traction. Which of the following actions should the nurse take?
Show the child's parent how to release tension on the bars.
Remove the vest for the child to sleep at night.
Check the child's pupillary response.
Apply a cervical collar if the child reports neck pain.
The Correct Answer is C
A. Show the child's parent how to release tension on the bars: The tension on the halo vest is adjusted by the healthcare provider, not by the parent. The nurse should not instruct the parent to release tension, as improper adjustments can lead to complications.
B. Remove the vest for the child to sleep at night: The halo vest should remain in place at all times, including during sleep, to maintain proper cervical traction and stabilization. Removing it may interfere with the healing process and cause further injury.
C. Check the child's pupillary response: Monitoring the pupillary response is important in a child with cervical traction to assess for any neurological changes. It helps identify signs of increased intracranial pressure or other neurological complications.
D. Apply a cervical collar if the child reports neck pain: The halo vest itself is designed to stabilize the neck, and the application of a cervical collar without provider guidance could interfere with the proper use of the traction system.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}
Explanation
Rationale:
- Type of cough: The characteristic "barking" cough is typical of acute laryngotracheobronchitis (also known as croup), which affects the upper airways and results in a harsh, barking cough. Pneumonia causes a productive cough, which is not noted here. The non-productive cough in this case is more indicative of laryngotracheobronchitis.
- Fever: A low-grade fever is common in acute laryngotracheobronchitis and is consistent with this case (38.2°C to 38.9°C). Pneumonia can also cause fever, especially a higher-grade fever, but the fever.
- Stridor: Inspiratory stridor is a hallmark sign of acute laryngotracheobronchitis, caused by narrowing of the upper airway, leading to a high-pitched sound when breathing in. Stridor is not typically associated with pneumonia, as pneumonia primarily affects the lungs and causes symptoms like cough, difficulty breathing, and chest pain rather than airway narrowing.
- Irritability: Irritability is common in acute laryngotracheobronchitis due to discomfort from the cough, difficulty breathing, and fever. Irritability can also be seen in pneumonia, particularly in young children who may be uncomfortable due to fever, difficulty breathing, and general malaise.
Correct Answer is C
Explanation
A. “I’m guessing your other parent did not do anything to stop this from happening.”
This statement makes assumptions about the other parent's actions and could lead to further conflict or discomfort for the adolescent. It’s important to avoid making judgments and focus on providing support.
B. “Your parent was wrong to hit you for coming home late.” This statement may come across as judgmental or accusatory, which could hinder communication and trust with the adolescent. It's important to validate their feelings first and address the situation appropriately.
C. “It is not your fault that this happened to you.” This response is empathetic and supportive. It reassures the adolescent, which is an important step in helping them feel safe and understood. It also provides an opportunity for further discussion about their safety.
D. “I won’t tell anyone else about this unless you say it’s okay.” While privacy is important, this could be misleading. In cases of abuse, the nurse is required to report the situation to protect the adolescent, even if they don't consent.
Complete the following sentence by using the lists of options.
The nurse should recommend to