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 B
Explanation
A. Paroxysmal coughing: This intense, spasmodic coughing is typical of pertussis (whooping cough) and is not a feature of rubeola. Rubeola primarily affects the respiratory tract differently, with symptoms like cough but not the characteristic whooping sound.
B. Koplik spots: These small, white or bluish-white lesions on the buccal mucosa are pathognomonic for rubeola and usually appear 1–2 days before the characteristic measles rash. They provide an early clinical clue for diagnosis and help differentiate rubeola from other viral illnesses.
C. Steatorrhea: The presence of fatty stools indicates malabsorption, often due to gastrointestinal disorders like cystic fibrosis or celiac disease. Rubeola does not typically affect fat absorption or cause gastrointestinal symptoms of this type.
D. Lymphadenopathy: While some viral infections cause swollen lymph nodes, rubeola usually presents with generalized symptoms like fever and rash rather than significant lymphadenopathy. Lymph node enlargement may occur but is not a defining feature.
Correct Answer is D
Explanation
A. Hematemesis: Vomiting blood is not a typical finding in celiac disease; it usually indicates gastrointestinal bleeding from other causes such as ulcers or esophageal varices. Celiac disease primarily affects nutrient absorption rather than causing direct bleeding.
B. Redcurrant, jelly-like stools: This type of stool is characteristic of intussusception, a condition where part of the intestine telescopes into itself causing obstruction and bleeding. It is unrelated to the malabsorption seen in celiac disease.
C. Increased hemoglobin level: Celiac disease commonly causes malabsorption leading to iron deficiency anemia, which results in decreased hemoglobin levels. An increased hemoglobin level would not be expected because nutrient deficiencies impair red blood cell production.
D. Pale, oily stools: Steatorrhea, characterized by pale, bulky, and oily stools, occurs due to fat malabsorption in celiac disease. This reflects damage to the intestinal villi by gluten, which impairs digestion and absorption of fats and other nutrients. It is one of the hallmark clinical features of celiac disease.
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