The nurse in a school clinic is caring for a 7-year-old girl who comes in for epistaxis. The nurse will initiate which of the following interventions? (Select the 2 responses that apply)

Apply a heat pack to the bridge of the nose.

Lightly suction blood from nares and mouth.

Have the child tilt her head forward.

Have the child sit upright.

Answer and Explanation

The Correct Answer is C

Choice A reason: Applying a heat pack to the bridge of the nose is not recommended as it may increase blood flow and worsen the bleeding.
Choice B reason: Lightly suctioning blood from nares and mouth is not typically necessary and could be uncomfortable for the child.
Choice C reason: This is one of the correct choices. Tilting the head forward prevents blood from flowing down the throat, which can cause nausea or vomiting.
Choice D reason: This is one of the correct choices. Sitting upright reduces blood pressure in the veins of the nose and may help slow the bleeding.

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Correct Answer is C

Explanation

Choice A reason: Keeping alarm levels low is important to reduce stress and promote a healing environment, but it is not the most impactful intervention for personalized care.

Choice B reason: Dimming the lights at night helps maintain a normal sleep-wake cycle, which is beneficial but not as specific to the client's individual needs as continuity of care.

Choice C reason: Having the same nurses care for the patient on consecutive days can provide consistency and build trust, which is especially important for a child in critical condition.

Choice D reason: While visits from school friends can be uplifting, they may not be feasible or appropriate for a client in critical condition in the PICU. The priority is ensuring stable and consistent care.

A. Peer group acceptance B. Development of a sense of industry C. The child is old enough to manage their own insulin doses and finger sticks D. The child’s safety

Correct Answer is D

Explanation

Choice A reason: While peer group acceptance is important, it is not the primary concern in this situation.
Choice B reason: Developing a sense of industry is part of Erikson's stages of psychosocial development but is not the primary nursing concern here.
Choice C reason: Whether the child can manage their own insulin and finger sticks is important, but safety is the primary concern.
Choice D reason: This is the correct choice. Ensuring the child's safety is paramount, as the school needs to be aware of the child's condition in case of a diabetes-related emergency.

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The nurse in a school clinic is caring for a 7-year-old girl who comes in for epistaxis. The nurse will initiate which of the following interventions? (Select the 2 responses that apply)

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