A nurse is caring for a school-age child who has a head injury. Which of the following actions should the nurse perform?
Verify that the bedrails are padded.
Perform nasal suctioning.
Place the child in the Trendelenburg position.
Ensure the room has bright lighting.
The Correct Answer is A
A. Verify that the bedrails are padded: Padded bedrails help prevent injury from accidental falls or seizures, which are common risks in children with head injuries. This safety measure minimizes further trauma and promotes a safer environment.
B. Perform nasal suctioning: Nasal suctioning should be avoided in children with head injuries because it can increase intracranial pressure and potentially cause further brain injury or bleeding.
C. Place the child in the Trendelenburg position: The Trendelenburg position (head lower than feet) can increase intracranial pressure and worsen cerebral edema, so it is contraindicated in head injury management.
D. Ensure the room has bright lighting: Bright lighting may cause discomfort or increase stimulation, potentially exacerbating symptoms such as headache or irritability in a child with a head injury. A calm, dimly lit environment is preferable.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. You need to keep the area exposed to air and direct sunshine: Exposing the radiation site to direct sunlight can cause further skin damage, increase the risk of burns, and worsen irritation. The area should be protected from sunlight during and after radiation therapy.
B. You should get an abdominal binder and try to keep the area covered: While covering the area may protect it, using tight or restrictive items like an abdominal binder can cause friction and pressure, potentially worsening skin irritation and impairing circulation.
C. Apply some triple antibiotic ointment to help the dryness and itching: Topical antibiotics are not routinely recommended for radiation skin care unless there is an active infection. Overuse of ointments can sometimes trap moisture, leading to maceration or further skin breakdown.
D. Do not wash the area with strong soaps and do not rub the area dry, just pat it dry: Using mild soap and gently patting the skin dry helps preserve skin integrity by preventing additional irritation and dryness. This approach minimizes trauma to the sensitive irradiated skin and supports healing.
Correct Answer is A
Explanation
A. Administer glucagon to the vastus lateralis: Glucagon is the treatment of choice for severe hypoglycemia when the child is unable to safely swallow or is experiencing altered mental status. It stimulates glycogen breakdown, rapidly increasing blood glucose.
B. Administer D/W intravenous fluids: Dextrose-containing IV fluids are used to treat hypoglycemia if IV access is available, but glucagon administration is preferred initially if the child is unconscious or unable to take oral glucose safely.
C. Give the child a candy bar: While candy bars provide sugar, they require chewing and swallowing, which may not be safe due to the child's altered mental status and risk of aspiration.
D. Give the child 3 to 6 oz of orange juice: Orange juice is appropriate for mild hypoglycemia when the child is alert and able to swallow safely, but altered mental status indicates a more severe condition needing immediate glucagon or IV glucose.
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