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 A
Explanation
Rationale:
A) Using an automated lancet device provides a controlled and consistent depth of puncture for the heel stick, minimizing discomfort and risk of injury.
B) Applying limb restraints is unnecessary and could cause distress to the infant.
C) Puncturing the heel at the inner aspect may not be the appropriate site for the heel stick.
D) Cleansing the area with povidone iodine is not necessary for a routine heel stick procedure.
Correct Answer is A
Explanation
Rationale:
A) The nurse should use a 5 French urinary catheter for the 13-month-old toddler.
This is because the size of the catheter should be appropriate for the age and weight
of the child, and a smaller catheter will cause less trauma and discomfort to the urethra.
B) A 12 French catheter might be too large and could cause trauma to the urethra in a 13-month-old toddler.
C) A 10 French catheter might be too large and could cause trauma to the urethra in a 13-month-old toddler.
D) A 14 French catheter is larger and may be too invasive for a 13-month-old toddler.
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