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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Related Questions
Correct Answer is B
Explanation
A. No head lag when pulled into a sitting position: By 2 months, some head lag may still be present when pulling the infant to a sitting position. Full control of the head without lag typically develops closer to 4 months of age.
B. Lifts head 45° when lying prone: At 2 months, infants generally can lift and hold their head at about a 45-degree angle when placed on their stomach. This demonstrates early neck muscle strength and control appropriate for this age.
C. Rolls over from abdomen to back: Rolling over usually occurs later, around 4 to 6 months. It is not an expected gross motor milestone for a 2-month-old infant.
D. Rolls over from back to abdomen: This is a more advanced motor skill that typically develops between 5 to 6 months of age and would not be expected at 2 months.
Correct Answer is A
Explanation
A. "Surgical repair is the recommended treatment for infants younger than 6 months old." For infants with coarctation of the aorta, especially those under 6 months, surgical repair is typically the preferred treatment. It offers definitive correction of the obstruction and helps prevent complications like heart failure or hypertension.
B. "The obstruction will be treated with a medication called indomethacin.": Indomethacin is used to close a patent ductus arteriosus (PDA), not to treat coarctation of the aorta. In fact, in some cases of coarctation, maintaining ductal patency with prostaglandins is temporarily helpful before surgery.
C. "Most cases resolve spontaneously without treatment by 12 months of age.": Coarctation of the aorta does not resolve on its own. Without intervention, it can lead to severe complications including congestive heart failure, poor perfusion, and even death.
D. "The cardiologist will monitor your infant closely until they are able to receive treatment with a heart transplant.": A heart transplant is not a standard treatment for coarctation of the aorta. Most infants with this condition are treated successfully with surgical or catheter-based interventions, not transplantation.
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