A school-aged child develops a nosebleed (epistaxis). Which action should the nurse take?

Turn the child's head to the side and press on the nasal ridge.

Elevate the head of the bed slightly and apply pressure to the forehead.

Sit the child upright and apply pressure to the sides of the nose.

Keep the child flat and apply pressure to the bridge of the nose.

Answer and Explanation

The Correct Answer is C

A. Turning the head to the side is not recommended, as it can cause blood to drain into the throat.

B. Applying pressure to the forehead does not help control nasal bleeding.

C. Sitting upright and applying pressure to the sides of the nose is the correct action to stop the bleeding and prevent blood from going down the throat.

D. Keeping the child flat can increase the risk of blood entering the airway, which can lead to aspiration.

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Correct Answer is B

Explanation

A. These vital signs are generally within expected ranges for a 2-year-old child.

B. A blood pressure of 79/40 mm Hg is low for a 2-year-old, and the elevated heart rate of 135/min and increased respirations suggest that the child may be experiencing significant distress or volume depletion, requiring immediate attention.

C. These vital signs are within normal limits for a 2-year-old child.

D. Although the blood pressure is on the lower end of normal and heart rate is slightly elevated, these findings are less concerning than option B.

A. Discuss the assessment findings with the primary care provider. B. Utilize social work for referral to early intervention. C. Provide the parents with pamphlets for support groups for children with developmental delays. D. Educate the parents on the developmental delays their child is diagnosed with.

Correct Answer is A

Explanation

A. The priority is to discuss the findings with the primary care provider to determine the next steps in diagnosis and intervention. Early identification and referral are crucial for addressing developmental delays.

B. Referring to early intervention is important but should follow the discussion with the primary care provider to ensure an appropriate and coordinated response.

C. Providing pamphlets is supportive but secondary to initiating a formal evaluation and intervention process.

D. Educating the parents is essential, but it should be based on a confirmed diagnosis and plan developed in collaboration with healthcare providers.

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A school-aged child develops a nosebleed (epistaxis). Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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