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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Administer IV antibiotics: While timely antibiotic administration is critical for treating osteomyelitis, obtaining cultures before starting antibiotics ensures accurate identification of the causative organism and appropriate therapy.
B. Obtain a blood culture: Collecting blood cultures first is the priority to identify the infection source and guide targeted antibiotic treatment. This step should precede antibiotic administration whenever possible.
C. Request a referral for physical therapy: Physical therapy is an important part of the long-term management of osteomyelitis to maintain mobility and prevent complications. However, it is not the immediate priority; identifying and treating the infection takes precedence.
D. Record intake and output: Monitoring fluid balance is important for overall care but does not take precedence over identifying the infectious agent and initiating treatment.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
|
Findings |
Indication of potential Improvement |
Indication of potential worsening condition |
|
WBC count |
✓ |
|
|
Temperature |
✓ |
|
|
Wound assessment |
✓ |
|
|
Weight-bearing ability on the affected leg |
✓ |
- WBC count: The WBC count increased from 14,000 to 15,000/mm³, indicating a persisting or intensifying systemic inflammatory response. This could reflect an ongoing or worsening infection despite treatment and warrants continued monitoring.
- Temperature: The adolescent’s temperature decreased from 38.8°C to 37.6°C, indicating reduced systemic inflammatory response and a likely response to antibiotic therapy.
- Wound assessment: The area of induration decreased from 6 x 6 cm to 5 x 5 cm, suggesting local improvement in inflammation and effectiveness of treatment.
- Weight-bearing ability on affected leg: The adolescent was able to ambulate twice and tolerated it well, suggesting reduced pain, improved mobility, and stabilization of the local infection.
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