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. "I can offer popcorn as a snack food." Popcorn is gluten-free and safe for children with celiac disease.
B. "I will make sandwiches on rye bread." Rye contains gluten and should be avoided.
C. "I will purchase graham crackers to pack in their lunchbox." Graham crackers often contain gluten and are unsuitable unless specifically labeled gluten-free.
D. "I can make beef barley soup for dinner." Barley contains gluten and is not safe for children with celiac disease.
Correct Answer is C
Explanation
A. Capillary refill greater than 4 seconds: This indicates severe hypovolemia, not moderate.
B. Bradycardia: Bradycardia is uncommon in hypovolemia and may occur late as a sign of decompensation, especially in infants.
C. Tachypnea. Tachypnea is a compensatory response to hypovolemia as the body attempts to improve oxygenation and circulation.
D. Lethargy: While lethargy is a concerning sign, it is associated with more severe dehydration than moderate hypovolemia.
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