A nurse is contributing to the plan of care for a newly admitted adolescent.
A nurse is contributing to the plan of care for a newly admitted adolescent. Which of the following interventions should the nurse include?
Suction the client's airway every 2 hr.
Maintain the client's head of the bed at 30°.
Keep the client's room well lit.
Check the client's temperature every 8 hr.
The Correct Answer is B
A: Suctioning the client's airway every 2 hours is not indicated based on the provided information. The adolescent does not have a condition that compromises airway clearance, and routine suctioning can cause trauma or stimulate a vagal response, potentially leading to bradycardia.
B: Maintaining the client's head of the bed at 30° is appropriate for reducing intracranial pressure and facilitating venous drainage. The patient's symptoms of nuchal rigidity and severe headache suggest increased intracranial pressure, possibly due to meningitis, which is supported by the diagnostic results.
C: Keeping the client's room well lit is not advisable as the patient reports photophobia, which is a sensitivity to light. A well-lit room could exacerbate discomfort and pain.
D: Checking the client's temperature every 8 hours is important but not the priority intervention. The patient's condition requires more frequent monitoring due to the positive blood culture and sensitivity, indicating an active infection. More frequent temperature checks would be warranted.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Giving the infant a bottle immediately before bedtime can actually exacerbate gastroesophageal reflux, as lying down right after feeding can increase the likelihood of regurgitation.
Choice B reason:
Switching to a soy-based formula is not the first-line intervention for gastroesophageal reflux. Additionally, soy-based formulas are not recommended for all infants and should be used under specific circumstances.
Choice C reason:
This statement is correct. Keeping the infant at a 30° angle for 1 hour following each feeding can help reduce the likelihood of gastroesophageal reflux. This position helps gravity keep the stomach contents from flowing back up into the esophagus.
Choice D reason:
Limiting formula feedings to every 6 hours may not be appropriate for a 2-month-old infant, as they typically require more frequent feedings for proper growth and development.
Correct Answer is D
Explanation
Choice A reason:
Tinnitus (ringing in the ears) is not a typical symptom of a vaso-occlusive crisis in sickle cell anemia.
Choice B reason:
Pruritus (itching) is not a typical symptom of a vaso-occlusive crisis in sickle cell anemia.
Choice C reason:
Polyuria (excessive urination) is not a typical symptom of a vaso-occlusive crisis in sickle cell anemia.
Choice D reason:
Abdominal pain is a common symptom of a vaso-occlusive crisis in sickle cell anemia. This pain is due to the obstruction of blood flow in the small vessels of the abdomen, leading to tissue
ischemia and pain.
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