A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
Insomnia
Irritability
Diarrhea
Hypothermia
The Correct Answer is B
Rationale:
A) Insomnia is a sleep disorder and is not typically associated with head injuries unless there is a concurrent neurological complication.
B) Irritability can be a sign of increased intracranial pressure following a head injury and should be promptly reported for further evaluation.
C) Diarrhea is not a common manifestation of head injuries and would not typically be included in monitoring and reporting instructions.
D) Hypothermia is not typically associated with head injuries unless there is a severe injury with shock, and it is not a common manifestation requiring monitoring in the acute phase of head injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A) This indicates a misunderstanding or lack of awareness regarding postoperative mobility expectations.
B) Beginning range-of-motion exercises on the first postoperative day indicates an understanding of the importance of early mobilization for recovery.
C) This may or may not be accurate depending on the individual's recovery progress, but it does not specifically demonstrate understanding of the teaching.
D) This indicates awareness of postoperative care but does not specifically address the immediate postoperative period.
Correct Answer is C
Explanation
Rationale:
A) Inability to hold a bottle is typically achieved by 4-6 months, so it might indicate a developmental delay.
B) Palmar grasp is a primitive reflex typically seen in newborns, and it should be replaced by more voluntary grasping patterns by 8 months.
C) Sitting unsupported is a milestone typically achieved by 6-8 months, indicating expected growth and development at 8 months.
D) Forcing the tongue outward when touched might indicate tongue thrust reflex, which should typically disappear around 4-6 months.
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