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
Thebehaviourdescribed,wherethechildappearstobestaringinto space,is characteristicof
B.Absenceseizures.
Absence seizures, also known as petit mal seizures, are a type of generalized seizure thatprimarily affects children. These seizures are brief and usually last for a few seconds. Duringan absence seizure, the child may appear to be staring blankly into space, unaware of theirsurroundings.Theymaynot respond to stimuli orengagein anypurposefulactivity.After theseizure ends, the child typically resumes their previous activity without any memory of theseizure.
Atonic seizures in (option A) is incorrect because it involves a sudden loss of muscle tone,leadingtoalimp or "drop"in theperson.
Simple partial seizures in (option C) are focal seizures that affect a specific region of thebrain,causinglocalizedsymptoms suchas twitchingor tinglinginaparticularbodypart.
Tonic-clonic seizures in (option D) also known as grand mal seizures, is incorrect because itinvolves a combination of muscle rigidity (tonic phase) and jerking movements (clonicphase).
Therefore, based on the description provided, the behaviour of staring into space ischaracteristic of B. Absence seizures. It is important for the child to be evaluated by ahealthcare professional for an accurate diagnosis and appropriate management of theirseizures.
Correct Answer is B
Explanation
These symptoms are indicative of hypoglycaemia, which occurs when the blood sugar levels drop too low. Providing a source of fast-acting carbohydrates, such as orange juice, can quickly raise the child's blood sugar levels and alleviate the symptoms.
Administering insulin (Option A) is incorrect because it is not appropriate in this situation because it would further lower the child's blood sugar levels.
Offering water (Option C) is incorrect because it would not effectively address the low blood sugar.
Glucagon (Option D) is incorrect because it is typically used in severe cases of hypoglycaemia when the child is unconscious or unable to swallow, and it requires a prescription. In this case, providing orange juice is the safest and most appropriate initial intervention. However, it is important to seek medical attention and inform the child's healthcare provider about the incident.
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