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 B
Explanation
A functional assessment is an evaluation of an individual's ability to perform activities of daily living (ADLs), which includes tasks such as bathing, dressing, toileting, eating, and mobility. Falls are a common and significant issue among older adults and are a leading cause of injury and hospitalization. Therefore, it is important to assess the client's risk of falling and inquire about any recent falls to develop an appropriate plan of care to prevent falls.
Encouraging the client to lie as still as possible during the assessment is not appropriate as it may not provide an accurate evaluation of the client's ability to perform ADLs.
Additionally, it is important to assess the client's functional status in a way that is safe and comfortable for them.
Assisting the client with values clarification about end-of-life care options is not appropriate during a functional assessment as it is not directly related to the client's ability to perform ADLs.
Asking the client how often episodes of sundowning are experienced is not appropriate during a functional assessment as sundowning is a symptom of dementia and is not directly related to the client's ability to perform ADLs.
Correct Answer is C
Explanation
Given the client's difficulty with memory, concentration, and recent life changes, it is
important for the nurse to acknowledge the possibility of delirium as a potential cause of the client's symptoms. Delirium is an acute state of confusion that can be caused by various factors, including physical illness, medication side effects, and emotional stressors. It is often reversible when the underlying cause is identified and treated.
By mentioning the possibility of delirium and its potential reversibility, the nurse opens up the conversation to exploring other factors that may be contributing to the client's symptoms. This response also provides hope to the family by suggesting that the client's condition may improve with appropriate interventions and management.
Stating that dementia resulting from Alzheimer's disease is often reversible even in the late stages is incorrect. Alzheimer's disease is a progressive neurodegenerative disorder that currently has no cure, and the symptoms tend to worsen over time.
Reversibility is not typically associated with Alzheimer's disease.
Indicating that the client's symptoms of dementia are permanent due to age is a generalization and may not be accurate. While age is a risk factor for certain types of dementia, such as Alzheimer's disease, it does not mean that all memory and cognitive difficulties in older adults are irreversible.
Suggesting that delirium is often a sign of underlying mental illness and institutionalization is necessary is not appropriate. Delirium is a medical condition that requires thorough assessment and appropriate management, including addressing any underlying causes. Institutionalization may be considered in certain situations, but it is not the primary focus of communication in this context.
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