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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Measuring the child's abdominal circumference:

This is the correct action. Assessing the child's abdominal circumference is essential in monitoring the size of the Wilms' tumor and evaluating for any signs of abdominal distention or growth. Changes in abdominal circumference can provide valuable information about the progression of the tumor and any potential complications.

B. Palpating the child's abdomen:

Palpating the child's abdomen is an essential part of the physical examination to assess for the presence of a mass or any tenderness. However, in the case of a child with a known Wilms' tumor, palpation should be performed gently to avoid causing discomfort or disturbing the tumor.

C. Providing clear liquids up to 1 hr prior to surgery:

Providing clear liquids up to 1 hour prior to surgery is not appropriate for a child undergoing surgery, especially if anesthesia is involved. Preoperative fasting guidelines typically require clear liquids to be stopped a few hours before surgery to reduce the risk of aspiration.

D. Continuously monitoring the child's oxygen saturation:

Continuous monitoring of the child's oxygen saturation is an essential aspect of perioperative care, but it is not specific to the preoperative assessment for a child with Wilms' tumor. Oxygen saturation monitoring is typically performed throughout the perioperative period to ensure adequate oxygenation during surgery and recovery.

A. "Schedule a time for your child to receive the pneumococcal vaccine within 2 weeks." B. "Provide your child with their own towel for drying their face and hands at home." C. "Replace your child's toothbrush 24 hours after beginning antibiotic therapy." D. "Your child can return to school 24 hours after their first does of antibiotics." E. "Replace your child's orthodontic appliances prior to beginning antibiotic therapy."

Correct Answer is ["B","C","D"]

Explanation

A. "Schedule a time for your child to receive the pneumococcal vaccine within 2 weeks."

This statement is incorrect. Pharyngitis caused by group A beta-hemolytic streptococci (GABHS) is typically treated with antibiotics, but it does not necessitate pneumococcal vaccination. Pneumococcal vaccination is recommended for other purposes, such as preventing pneumonia and invasive pneumococcal disease.

B. "Provide your child with their own towel for drying their face and hands at home."

This statement is correct. Group A streptococci (GAS) can be transmitted through respiratory droplets or by direct contact with infected secretions. Providing the child with their own towel can help prevent the spread of the infection to other family members.

C. "Replace your child's toothbrush 24 hours after beginning antibiotic therapy."

This statement is correct. It is recommended to replace the child's toothbrush after starting antibiotic therapy to reduce the risk of re-infection with group A streptococci (GAS).

D. "Your child can return to school 24 hours after their first dose of antibiotics."

This statement is correct. After initiating antibiotic therapy for GABHS pharyngitis, the child is usually considered non-contagious and can return to school after completing 24 hours of antibiotic treatment.

E. "Replace your child's orthodontic appliances prior to beginning antibiotic therapy."

This statement is incorrect. There is no specific recommendation to replace orthodontic appliances before starting antibiotic therapy for GABHS pharyngitis unless otherwise advised by a dentist or healthcare provider.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A nurse is providing discharge teaching to the parent of a school-age child who has pharyngitis caused by group A B-hemolytic streptococci (GABHS). Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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