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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Instilling erythromycin ophthalmic ointment in the newborn's eyes is important to prevent neonatal conjunctivitis, but drying the newborn takes precedence to prevent heat loss and stimulate breathing immediately after birth.
B. Weighing the newborn and placing identification bracelets can be done after drying the newborn.
C. Placing identification bracelets on the newborn is important for identification purposes but does not take precedence over drying the newborn to prevent heat loss and stimulate breathing.
D. Dry the newborn: Drying the newborn is the priority immediately after birth to prevent heat
loss and stimulate breathing. The newborn is wet from amniotic fluid and may be cold due to the temperature difference between the intrauterine and extrauterine environment. Drying the newborn with a warm, soft towel helps to prevent hypothermia and promotes the initiation of breathing, which is essential for oxygenation and lung expansion. This action supports the
newborn's transition to extrauterine life and sets the stage for subsequent assessments and interventions.
Correct Answer is C
Explanation
A. Wearing an N95 respiratory mask is not typically required for routine care of a toddler with respiratory syncytial virus unless performing procedures that generate aerosols.
B. Negative pressure rooms are generally reserved for patients with airborne infections like
tuberculosis; respiratory syncytial virus does not typically require isolation in a negative pressure room.
C. Using a designated stethoscope helps prevent the spread of infection to other patients by avoiding cross-contamination.
D. Removing the disposable gown after leaving the toddler's room is appropriate for maintaining infection control but is not specific to caring for a toddler with respiratory syncytial virus.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.