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 D
Explanation
A. While play therapy can be beneficial, it is not the most relevant action for a 10-year-old child in this context.
B. Discouraging visits from friends can lead to feelings of isolation and is not aligned with Erikson's stage of industry vs. inferiority, where children need opportunities for social interaction.
C. A consistent routine is important for children to feel secure and reduce anxiety.
D. Encouraging the child to continue with schoolwork fosters a sense of accomplishment and helps maintain normalcy, promoting their psychosocial development.
Correct Answer is ["A","C","D","E"]
Explanation
A. Management of tantrums is an essential skill for parents of toddlers, as it helps manage emotional outbursts.
B. While trust is important, it is more relevant in infancy. Toddlers focus on developing autonomy and control.
C. Dental care is crucial for toddlers as their teeth emerge, and it's important to establish good oral hygiene habits early.
D. Encouraging cooperative play is important for social and emotional development in toddlers.
E. Toddlers have increased caloric needs due to their rapid growth and activity levels.
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