A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?

Refer the family to a chronic pain support group.

Request a change in medication from the provider.

Review the child's electronic pain diary.

Set up an appointment with the school nurse.

Answer and Explanation

The Correct Answer is C

A.   Referring the family to a chronic pain support group may be beneficial but does not address the immediate need to assess the child's current condition and management.
B.   Requesting a change in medication from the provider may be necessary but should be based on a thorough assessment, including reviewing the child's pain diary.
C.   Reviewing the child's electronic pain diary allows the nurse to gather important information about the frequency, severity, triggers, and effectiveness of current interventions for migraine headaches, guiding further assessment and management.
D.   While involving the school nurse may be part of the child's care plan, it does not address the immediate need to assess the child's current condition and management.

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Correct Answer is D

Explanation

A. The Sims position is a lateral position used for procedures such as rectal examinations and enemas and is not typically indicated for managing increased intracranial pressure.
B. The supine position may worsen increased intracranial pressure by increasing venous return and intracranial pressure.
C. The left lateral position may be used in specific circumstances, such as to relieve pressure on the vena cava in pregnancy, but it is not typically indicated for managing increased intracranial pressure.
D. Positioning the client in Low-Fowler's position (with the head of the bed elevated approximately 15-30 degrees) helps facilitate venous drainage from the brain, thereby reducing intracranial pressure. This position promotes optimal cerebral perfusion and helps manage increased intracranial pressure.

A. Flush the tube with 0.9% sodium chloride. B. Replace the NG tube every 24 hr. C. Position the client supine in bed. D. Increase the suction pressure as tolerated.

Correct Answer is A

Explanation

A. Flushing the NG tube with 0.9% sodium chloride helps maintain patency and prevents obstruction. It is a standard practice to flush NG tubes before and after administering medications or feedings.
B. NG tubes are not routinely replaced every 24 hours unless there is a specific clinical indication to do so.
C. The position of the client depends on the clinical situation, but supine position alone does not address NG tube care.
D. Suction pressure should be set according to the physician's orders and the patient's tolerance, but it should not be increased arbitrarily without clinical indication.

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A nurse is caring for a child who reports migraine headaches for the past 4 months. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing Increased Intracranial pressure following a head Injury. In which of the following positions should the nurse place the client?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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