Exhibits
Complete the following sentence by using the lists of options.
The nurse should first address the child's
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Rationale for Correct Answers:
- Level of alertness: This is a primary indicator of neurological function and potential deterioration in a child with suspected meningitis. Altered alertness may signal increased intracranial pressure or brain involvement, and it requires immediate attention.
- Mental status: While related to alertness, mental status encompasses behavior, orientation, and responsiveness. It is important to monitor next to evaluate for progression of neurological compromise after ensuring the child is responsive.
Rationale for Incorrect Choices:
- Decreased appetite: A common symptom in many illnesses but not immediately life-threatening. It is not a priority in acute neurological assessment.
- Irritability: Can be an early sign of neurological irritation but is less critical than decreased alertness and changes in mental status.
- Hypoactive bowel sounds: This may reflect reduced gastrointestinal activity from illness or immobility but is not an urgent concern compared to neurological findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Obtain a prescription for lorazepam: Sedation may be used in some cases, but routinely sedating a toddler post-cleft lip and palate repair is not the first-line intervention to prevent incision site trauma.
B. Place the toddler in bilateral elbow restraints: Elbow restraints are commonly used to prevent toddlers from touching or injuring the surgical site after cleft lip and palate repair, protecting the incision during healing.
C. Place the child in a mummy restraint: Mummy restraints restrict the entire body and can increase distress and anxiety; they are generally avoided unless absolutely necessary.
D. Swaddle the toddler in a blanket: Swaddling can provide comfort and limit movement, but it is less effective than elbow restraints at specifically preventing the child from touching the incision site.
Correct Answer is A
Explanation
A. Verify that the bedrails are padded: Padded bedrails help prevent injury from accidental falls or seizures, which are common risks in children with head injuries. This safety measure minimizes further trauma and promotes a safer environment.
B. Perform nasal suctioning: Nasal suctioning should be avoided in children with head injuries because it can increase intracranial pressure and potentially cause further brain injury or bleeding.
C. Place the child in the Trendelenburg position: The Trendelenburg position (head lower than feet) can increase intracranial pressure and worsen cerebral edema, so it is contraindicated in head injury management.
D. Ensure the room has bright lighting: Bright lighting may cause discomfort or increase stimulation, potentially exacerbating symptoms such as headache or irritability in a child with a head injury. A calm, dimly lit environment is preferable.
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