A nurse is creating a plan of care for a child who is awake and responsive following an acute head injury. Which of the following interventions should the nurse include?
Place the child in a room with bright fluorescent lighting.
Initiate seizure precautions for the child.
Use the COMFORT scale to rate the child's pain.
Suction the child's nares to determine the presence of fluid.
The Correct Answer is B
A. Place the child in a room with bright fluorescent lighting.
This option is not appropriate because bright fluorescent lighting can be uncomfortable and potentially aggravate symptoms such as headache or sensitivity to light, which are common after a head injury. Therefore, it is not included in the plan of care.
B. Initiate seizure precautions for the child.
This intervention is appropriate because children with head injuries are at an increased risk of seizures. Seizure precautions may include ensuring a safe environment, such as padding the sides of the bed, removing any objects that could cause harm during a seizure, and closely monitoring the child's neurological status for signs of seizure activity.
C. Use the COMFORT scale to rate the child's pain.
While assessing and managing pain is important, the COMFORT scale may not be the most appropriate tool for evaluating pain in a child with a head injury. The nurse should use a pain assessment tool that is specifically designed for pediatric patients and is suitable for assessing pain in children with head injuries.
D. Suction the child's nares to determine the presence of fluid.
Suctioning the child's nares may be indicated if there are concerns about airway patency or respiratory secretions. However, it is not a routine intervention for all children with head injuries. The nurse should assess the child's respiratory status and use suctioning only if necessary based on clinical findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Preschoolers believe their illness is punishment for their misbehavior:This statement is true. Preschool-aged children often have a limited understanding of illness and may associate it with punishment. They might think that their illness is a consequence of something they did wrong. As a nurse, it’s essential to address these misconceptions and provide age-appropriate explanations to help them understand their condition better.
B. Preschoolers are interested in what happens to the body after death: Preschoolers may have curiosity about death and what happens afterward, but their understanding is typically limited. They may ask simple questions about death and may need age-appropriate explanations about the concept. Providing information in a sensitive and honest manner can help address their curiosity and alleviate fears.
C. Adolescents worry more about death than the physical changes that can occur as a result of the illness: Adolescents facing terminal illness may have complex emotions and concerns about both death and the physical changes associated with their illness. It's important to acknowledge and address both aspects of their experience, providing opportunities for adolescents to express their feelings and concerns in a supportive environment.
D. Toddlers personify death as being a type of monster: Toddlers often have limited understanding of death and may personify it in different ways, including as a monster or some other abstract concept. It's essential for guardians to provide comfort and reassurance to toddlers who may experience fear or confusion about death. Providing simple and concrete explanations about death, tailored to their developmental level, can help alleviate anxiety.
Correct Answer is D
Explanation
A. Ophthalmologist: This healthcare professional specializes in the diagnosis and treatment of eye disorders. While eye problems can occur in infants, congenital talipes equinovarus specifically involves foot deformities rather than eye issues. Therefore, a referral to an ophthalmologist wouldn't be appropriate for this condition.
B. Nutrition counselor: A nutrition counselor provides guidance on diet and nutrition-related issues. While nutrition is essential for overall health, it's not directly related to the treatment of congenital talipes equinovarus. Therefore, a referral to a nutrition counselor wouldn't typically be part of the care plan for this condition.
C. Speech therapist: Speech therapists, also known as speech-language pathologists, specialize in evaluating and treating communication and swallowing disorders. However, congenital talipes equinovarus doesn't affect speech or swallowing. Therefore, a referral to a speech therapist wouldn't be relevant for this condition.
D. Orthopedic specialist: An orthopedic specialist is a healthcare professional who specializes in the diagnosis and treatment of musculoskeletal conditions, including congenital abnormalities like clubfoot. They are trained to assess the severity of the deformity and develop a treatment plan, which may include non-surgical or surgical interventions to correct the foot alignment. Therefore, a referral to an orthopedic specialist is the most appropriate choice for an infant with congenital talipes equinovarus.
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