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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Providing a detailed description of how burns occurred may suggest a plausible explanation, but it does not necessarily indicate abuse.
B. Denying discomfort despite the presence of burns may suggest emotional detachment or an attempt to conceal the severity of the injuries, which can be indicative of abuse.
C. Describing strong relationships with peers is a typical and healthy sign of social development and does not indicate abuse.
D. Reluctance to leave home may suggest anxiety or attachment to family, but it is not necessarily indicative of abuse.
Correct Answer is A
Explanation
A. Accidents, particularly motor vehicle accidents, are the leading cause of death among adolescents. This is due to factors such as risky behavior, inexperience, and a higher likelihood of being involved in car accidents.
B. Suicide is a significant cause of death in adolescents but does not surpass accidents in frequency.
C. Homicide is another concern but is less common than accidental deaths.
D. Cancer is a leading cause of death in children, but not in adolescents, where accidents are more prevalent.
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