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.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A) Placing the child in a forward-facing car seat before the appropriate age and size increases the risk of injury.
B) Placing the child in the front seat, even in a rear-facing car seat, is not recommended due to the risk of airbag deployment.
C) Booster seats are used for older children who have outgrown their forward-facing car seats, but are not yet big enough to use the seat belt properly. Booster seats should be used until the child is at least 4 feet 9 inches tall and between 8 and 12 years old.
D) Placing the child in a rear-facing car seat until age 2 is recommended by safety guidelines to provide optimal protection for the child's head, neck, and spine.
Correct Answer is D
Explanation
Rationale:
A) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.
B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.
C) A respiratory rate of 40/min is within the normal range for an infant.
D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.
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