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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Explaining body changes to a toddler may not be effective due to their limited understanding at this developmental stage.
Choice B reason: Maintaining normal routines provides a sense of security and normalcy, which is crucial for a toddler's emotional well-being, especially during a serious illness.
Choice C reason: Allowing the child to talk about the illness can be therapeutic, but toddlers may not have the verbal skills to express complex emotions or understand their condition.
Choice D reason: While encouraging friends to visit can provide social support, it is not as fundamental as maintaining daily routines that offer stability in the child's life. Maintaining normal routines is the most comforting and beneficial intervention for a toddler in this situation.
Correct Answer is B
Explanation
Choice A reason: While symptoms of infection are important to assess, they are not the immediate priority following vaccine administration.
Choice B reason: Anaphylaxis is a rapid, potentially life-threatening allergic reaction that can occur after vaccination, making it the priority assessment.
Choice C reason: Pain at the injection site is common and expected, but it is not as critical as assessing for anaphylaxis.
Choice D reason: Myalgia, or muscle pain, may occur after vaccination but is not the immediate priority for assessment.
Choice E reason: Hyperthermia, or elevated body temperature, could indicate an adverse reaction; however, anaphylaxis is the most urgent concern to address post-vaccination.
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