A nurse is receiving change of shift report on four children. Which of the following children should the nurse assess first?
A toddler who has a concussion and an episode of forceful vomiting
An adolescent who was placed into halo traction 1 hr ago and rates his pain at a 6 on a 0 to 10 scale
A school-age child who has acute glomerulonephritis and brown-colored urine
An adolescent who has infective endocarditis and reports having a headache
The Correct Answer is A
A. Forceful vomiting in a child with a concussion could indicate increased intracranial pressure (ICP), which is a medical emergency. Vomiting is a common symptom of ICP, and prompt assessment is necessary to determine the severity of the concussion and prevent further complications.
B. Pain following halo traction is expected, and a pain score of 6 is moderate. The pain can be managed with appropriate interventions, and it does not indicate an immediate life-threatening situation.
C. Brown-colored urine in acute glomerulonephritis is concerning for hematuria, but it typically develops over several days and is not an acute emergency.
D. A headache in a patient with infective endocarditis could indicate a potential complication such as embolism or increased intracranial pressure, but it is not as immediately life-threatening as the signs of a concussion.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While consistency is important for children with autism, allowing for frequent rule adjustments can be confusing. Rules should be stable to help the child feel secure.
B. A flexible schedule that adjusts to the child's interests may not work well. Children with autism benefit from a predictable, structured routine.
C. Establishing a reward system for positive behavior is a key intervention. Positive reinforcement can encourage desired behaviors and support the child's development.
D. Children with autism often struggle with social interactions, and unsupervised imaginative play may result in challenges. Supervision is important to support safe and appropriate social engagement.
Correct Answer is A
Explanation
A. The nurse should notify the charge nurse of the situation to ensure that the client’s legal rights, autonomy, and best interests are considered in making decisions regarding treatment.
B. Offering an antiemetic is not the primary concern when the client is refusing treatment; the issue is the refusal of care.
C. Administering a sedative without addressing the underlying issue would not be appropriate and could violate the adolescent’s autonomy.
D. Starting the IV per the parent's request without the adolescent’s consent may violate the adolescent’s rights and should not be done without careful consideration of legal and ethical principles.
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