A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?

Perform active range-of-motion exercises.

Maintain the head at a midline position.

Suction the airway frequently.

Perform neurological checks every 4 hours.

Answer and Explanation

The Correct Answer is B

A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.

B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.

C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.

D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.

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Correct Answer is A

Explanation

A. Changing clothes after working in the field helps prevent pesticide residue from being transferred to other surfaces and reduces the risk of exposure to pesticides.

B. Applying petroleum jelly to the nostrils is not an effective method for minimizing exposure to pesticides and may not provide significant protection.

C. Wiping fruits and vegetables with a dry cloth may remove some surface dirt but is unlikely to effectively remove pesticide residues, especially if they have been absorbed into the produce.

D. Taking a hot shower after finishing work may help remove pesticide residues from the skin but does not address the potential for exposure from contaminated clothing or other surfaces.

A. Infuse 0.9% sodium chloride IV. B. Administer an antipyretic. C. Decrease the infusion rate to 75 mL/hr. D. Place the client in a left lateral position.

Correct Answer is A

Explanation

A. Infuse 0.9% sodium chloride IV - In the event of a hemolytic reaction, it's important to stop

the blood transfusion immediately and infuse normal saline to maintain intravascular volume and support renal perfusion.

B. Administer an antipyretic - While fever may occur with a hemolytic reaction, the priority is to stop the transfusion and provide supportive care with fluids.

C. Decrease the infusion rate to 75 mL/hr - Lowering the infusion rate is not appropriate when a hemolytic reaction occurs; stopping the transfusion is necessary.

D. Place the client in a left lateral position - Positioning changes will not address the hemolytic reaction; stopping the transfusion and providing supportive care are the priority.

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A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?

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