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. Visible contusions on all four extremities may indicate physical abuse, especially in the context of being brought to the emergency department by a family member. Reporting the

incident to Adult Protective Services is essential to ensure the safety and well-being of the client.

B. Interviewing the client with his adult child present may not be appropriate if there are concerns about potential abuse or coercion.

C. Forcing the client to answer every assessment question may not be appropriate if the client is in distress or unable to communicate freely.

D. Advising the client to consult a social worker may be appropriate, but reporting suspected abuse to Adult Protective Services is the priority action in this situation.

A. Justice B. Autonomy C. Nonmaleficence D. Veracity

Correct Answer is A

Explanation

A. Justice refers to fairness and equity in the distribution of resources and the treatment of

individuals. By spending an equal amount of time with each client regardless of their background or actions, the nurse is demonstrating the principle of justice.

B. Autonomy refers to respecting the right of individuals to make their own decisions about their healthcare. While important, it does not directly relate to the nurse's equal allocation of time.

C. Nonmaleficence refers to the duty to do no harm. While relevant to nursing care, it does not directly apply to the equal distribution of time among clients.

D. Veracity refers to truthfulness and honesty in communication. While important, it does not directly relate to the allocation of time among clients.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who was brought to the emergency department by his adult child. The client has visible contusions on all four extremities. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse in a substance use unit spends an equal amount of time with each of his assigned clients, even though some of the clients have committed serious crimes. Which of the following ethical principles is the nurse demonstrating?

Correct Answer is A

Explanation

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