Which is the most appropriate nursing action for a school-age child who has sustained a head injury and multiple fractures after being thrown from a horse and whose level of consciousness is variable?
Discuss with the family the child's previous history of injury.
Consult with the practitioner about what analgesia can be safely administered.
Explain that analgesia may mask signs of a decreasing level of consciousness.
Teach the family that adjunctives such as benzodiazepines are preferred for head injuries.
The Correct Answer is B
Choice A reason: Discussing the child's previous history of injury is important, but it does not address the immediate concern of pain management.
Choice B reason: Consulting with a practitioner to determine safe analgesia options is crucial for managing pain while also monitoring the child's variable consciousness levels.
Choice C reason: While it is true that analgesia can mask neurological symptoms, it is essential to manage pain effectively, and the healthcare team can monitor for changes in consciousness.
Choice D reason: Teaching the family about specific medications like benzodiazepines is not the most immediate concern and should be left to the practitioner's discretion based on the child's condition. Pain management and safety are the priorities.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: Meningitis is not typically associated with ADD/ADHD, making it a correct choice as an exception among the risk factors listed.
Choice B reason: A family history of ADD/ADHD is a known risk factor for these conditions.
Choice C reason: Exposure to environmental toxins is a recognized risk factor for developing ADD/ADHD.
Choice D reason: While gestational diabetes can have various effects on a child's health, it is not a recognized risk factor for ADD/ADHD, making this the correct answer.
Correct Answer is B
Explanation
Choice A reason: IV fluid replacement in DKA is typically isotonic, not hypertonic, to avoid rapid changes in osmolality.
Choice B reason: This is correct. While the total body potassium is depleted in DKA, the initial lab values often show hyperkalemia (high potassium) due to the metabolic acidosis, which shifts potassium out of the cells. This can lead to serious cardiac dysrhythmias and even cardiac arrest, making continuous cardiac monitoring and potassium level assessment a top priority.
Choice C reason: Monitoring for hypertension is important, but the primary concern in DKA is managing the acidosis and hyperglycemia.
Choice D reason: This is incorrect. Treatment for DKA involves a continuous IV infusion of regular insulin at a low, steady rate, not high doses of NPH insulin. NPH insulin is an intermediate-acting insulin and is not suitable for the acute management of DKA.
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