A nurse on a pediatric unit is admitting a 5-year-old child who has a submersion injury and is awake and alert. The parent asks the nurse why the child needs to stay in the facility. Which of the following responses should the nurse make?
"Your child needs mechanical ventilation."
"We need to observe your child for cerebral swelling."
"Your child needs to have an electroencephalogram."
"We need to perform an echocardiogram on your child."
The Correct Answer is B
A. "Your child needs mechanical ventilation." Mechanical ventilation is unnecessary if the child is awake and alert.
B. "We need to observe your child for cerebral swelling." Submersion injuries can lead to complications like cerebral edema or acute respiratory distress syndrome (ARDS), even if the child initially appears stable. Observation is essential to identify and address delayed complications.
C. "Your child needs to have an electroencephalogram." Electroencephalograms (EEGs) are not routine unless seizures or brain activity concerns are present.
D. "We need to perform an echocardiogram on your child." Echocardiograms are not standard for submersion injuries unless cardiac dysfunction is suspected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Face, legs, activity, cry, consolability (FLACC) scale: The FLACC scale is appropriate for children aged 2 months to 7 years and assesses pain based on non-verbal cues such as facial expression, leg movement, activity, crying, and consolability.
B. Oucher scale and C. FACES scale are more appropriate for children aged 3 years and older who can self-report their pain.
D. Visual analog scale (VAS) is suitable for older children (typically 8 years and older) who can understand the concept of a continuum of pain.
Correct Answer is C
Explanation
A. Warm extremities: Typically, in heart failure, extremities can feel cold due to poor circulation and reduced cardiac output.
B. Frequent headaches: Headaches are not a typical sign of heart failure in children. Although they can occur in some cases due to increased intracranial pressure, they are not characteristic of heart failure.
C. Distended neck veins: Distended neck veins are a hallmark sign of right-sided heart failure. It occurs when the heart is unable to efficiently pump blood, leading to congestion and fluid retention, which can cause blood to back up into the veins, resulting in visible distention.
D. Weight loss: Weight gain due to fluid retention is more common in heart failure. Weight loss may occur in more advanced or chronic cases due to decreased appetite and fluid shifts, but weight gain is the expected finding in early stages.
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