A 15-year-old patient with a closed head injury is admitted to the pediatric intensive care unit and is intubated. The nurse should monitor the patient for which symptom?
Neck vein distention.
Fixed, dilated pupils.
Shortness of breath.
Glycosuria.
The Correct Answer is B
Choice A rationale:
Neck vein distention might be seen in conditions affecting venous return to the heart, such as heart failure, but it's not a specific symptom of closed head injury.
Choice B rationale:
Fixed, dilated pupils are a classic sign of increased intracranial pressure. The pressure can compress the cranial nerves, leading to changes in pupillary size and reactivity.
Choice C rationale:
Shortness of breath is more related to respiratory issues and might not be directly linked to a closed head injury.
Choice D rationale:
Glycosuria, the presence of glucose in the urine, is not a primary symptom of closed head injury. It could be related to diabetes or other metabolic conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
The patient ties his shoelaces. This choice is incorrect as most 3-year-olds lack the fine motor skills required to tie shoelaces independently.
Choice B rationale:
The patient gives his first and last name. This choice is also incorrect, as most 3-year-olds might not have developed language skills to provide their full name accurately.
Choice C rationale:
The patient can tell time. This choice is unrealistic for a 3-year-old, as telling time involves cognitive and conceptual abilities that are not yet developed at this age.
Choice D rationale:
The patient draws a stick figure with six parts. This choice is correct. Around age 3, children usually start drawing simple figures with a head, arms, legs, and possibly facial features, totaling around six parts. This reflects appropriate developmental milestones for a child of this age.
Correct Answer is D
Explanation
Choice A rationale:
Wet diapers are a sign of hydration, not necessarily nutrition sufficiency.
Choice B rationale:
Introducing solids too early can lead to various issues; it's not linked to sleep improvement.
Choice C rationale:
Cow's milk isn't suitable for a newborn's consumption due to the potential for allergies and digestive issues.
Choice D rationale:
This choice accurately reflects hunger cues in a newborn, demonstrating an understanding of proper feeding.
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