A child is hospitalized after a serious motor vehicle crash and has developed increased urination. What action by the nurse takes priority?
Restrict dietary sodium intake.
Assess the daily serum sodium level.
Weigh the child daily.
Monitor the child's intake and output.
The Correct Answer is D
In this scenario, the child's increased urination after a serious motor vehicle crash may
indicate a potential issue with fluid balance. Monitoring the child's intake and output is the
priority action for the nurse. This involves accurately measuring and recording the fluids the
child consumes (intake) and the fluids the child eliminates through urine, sweat, and other
sources (output). By closely monitoring the child's intake and output, the nurse can assess the
child's fluid status and identify any abnormalities or imbalances that may require further
intervention.
Restrict dietary sodium intake in (option A) is incorrect because restricting dietary sodium
intake, may be necessary in certain situations, such as if the child has a known sodium
imbalance or hypertension. However, it is not the priority action in this scenario.
Assess the daily serum sodium level in (option B) is incorrect because assessing the daily
serum sodium level, is important to evaluate the child's electrolyte balance. However, it is not
the priority action compared to monitoring the child's intake and output.
Weigh the child daily in (option C) is incorrect because weighing the child daily, is a useful
measure to assess changes in fluid balance. However, it is not the priority action in this
scenario compared to monitoring the child's intake and output, which provides real-time
information on fluid balance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Hypothyroidismreferstoanunderactivethyroid glandthatdoesnotproduceenoughthyroidhormones. In newborns, this condition is known as congenital hypothyroidism. Thesymptoms mentioned—mottled skin, a large fontanel (soft spot on the baby's head), a largetongue,lethargy, anddifficultyfeeding—arecharacteristic ofhypothyroidism inneonates.
Mottledskincanoccur duetodecreasedcirculationandlow bodytemperatureassociatedwith hypothyroidism. A large fontanel and tongue are common physical features seen ininfants with hypothyroidism. Lethargy and poor feeding are also typical signs of thiscondition.
Hypoglycaemia in (option A) is incorrect because it refers to low blood sugar levels andusuallypresentswithdifferent symptomssuchas jitteriness,tremors,and sweating.
Hypocalcaemia in (option C) is incorrect because it is low calcium levels and can manifestwithsymptoms like muscle cramps, twitching,and seizures.
Phenylketonuria (PKU) in (option D) it is incorrect because it is a metabolic disordercharacterized by the inability to metabolize the amino acid phenylalanine, and it typicallypresentswith differentsymptoms such asintellectual disabilityandamustydoorto theskin.
Therefore, based on the symptoms described, hypothyroidism (B) is the most likely disorderinthisneonate. Itisimportanttoconsultahealthcareprofessionalforaproperdiagnosisandappropriatetreatment.
Correct Answer is B
Explanation
The primary concern when it comes to a synthetic cast is to keep it dry during bathing or showering. Moisture can weaken the cast material and lead to skin irritation or infection. Therefore, covering the cast with plastic and waterproof tape helps to protect it from getting wet.
Applying a heating pad to the cast if the child has swelling in the affected extremity in (Option A) is incorrect because applying a heating pad to the cast can increase the risk of burns and is not recommended. If the child has swelling in the affected extremity, it is important to elevate the limb and follow any specific instructions provided by the healthcare provider.
Splitting the cast if the child complains of numbness or pain in (Option C) is also incorrect. Splitting the cast, or attempting to modify or adjust it, should not be done without medical supervision. If the child complains of numbness or pain, it is important to notify the healthcare provider for further evaluation and appropriate management.
|
Wrapping the outer surface of the cast with an Ace bandage in (Option D) is incorrect as well. Wrapping the outer surface of the cast with an Ace bandage or any additional material is not recommended unless specifically instructed by the healthcare provider. It can affect the fit of the cast, alter the healing process, and potentially cause complications |
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today