Exhibits
The parents are at the bedside and state that each parent thought the other parent was watching the child. They are not sure how long he was in the pool or how he might have fallen in. The temperature of the pool was cool as the temperature outside was about 64 °F (17.8 °C).
Placed a cervical collar with the assistance of the physician. The child's pulse is 121 beats/minute, the airway is patent, and there are no signs of any bleeding.
Review H and P, nurse's note, laboratory results, orders, and imaging studies. What complications should the nurse monitor for in the next 6 to 8 hours? Select all that apply.
Cerebral edema
Acute asphyxia
Hypertension
Respiratory distress
Hyperthermia
Subdural hemorrhage
Correct Answer : A,D
Choice A rationale: Hypoxic-ischemic injury from submersion can lead to delayed cerebral edema. Monitoring is critical as the brain's inflammatory response to the initial insult often peaks several hours after the event.
Choice B rationale: Asphyxia is the initial event that occurred in the pool. By the time the child is admitted to the pediatric floor, the asphyxiation event has passed; the nurse now monitors for its aftereffects.
Choice C rationale: Near-drowning victims are more likely to experience hypotension due to myocardial depression or shifting fluid balances. Hypertension is not a typical expected complication in the immediate post-submersion recovery period.
Choice D rationale: Aspiration of water interferes with surfactant production and damages alveolar membranes, leading to pulmonary edema or ARDS. Respiratory status can deteriorate rapidly 6 to 8 hours after the initial insult.
Choice E rationale: The child was in cool water with an outdoor temperature of 64°F, making hypothermia the primary concern. Hyperthermia is not expected unless a secondary infection or a thermregulation failure occurs much later.
Choice F rationale: The head CT scan was negative for bleeding. Without a significant traumatic impact or pre-existing condition, a subdural hemorrhage is not a standard complication resulting from a submersion injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.4"]
Explanation
Calculate the total dosage required: 44 mcg/kg * 65 kg = 2860 mcg. Convert mcg to mg: 2860 mcg ÷ 1000 = 2.86 mg.
Divide by concentration: 2.86 mg ÷ 2 mg/mL = 1.43 mL.
Considering the vial contains 2 mg/mL, the nurse should administer around 1.43 mL, which can be rounded to 1.4 mL.
Correct Answer is A
Explanation
Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.
Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.
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