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.
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Related Questions
Correct Answer is A
Explanation
The statement that accurately describes the difference between the central nervous system (CNS) of a child and an adult is option A. The brain of a term infant weighs less than half of the weight of the adult brain. The brain undergoes significant growth and development during childhood and continues to develop until early adulthood. At birth, the brain is only a fraction of its adult weight, and it continues to grow and mature over time.
infant has 150 mL of cerebrospinal fluid (CSF) compared with 50 mL in the adult in (option B), is incorrect. The volume of CSF in the CNS is not a significant difference between children and adults.
coordination and fine motor skills develop as myelination of peripheral nerves progresses in (option C), is an incorrect statement. Myelination is an ongoing process that occurs throughout childhood and contributes to the development of coordination and fine motor skills.
papilledema is a common manifestation of increased intracranial pressure (ICP) in the very young child in (option D), is not correct. Papilledema refers to swelling of the optic disc and is not commonly seen in very young children. Signs of increased ICP in young children may present differently compared to adults and can include altered mental status, irritability, vomiting, and changes in vital signs.
Correct Answer is A
Explanation
The scenario describes a 14-year-old male who seems to be always eating, but his weight is appropriate for his height. In this case, it is important to reassure the parents that the behaviour may not necessarily be a cause for concern.
Option A provides an accurate response by explaining that for weight gain to occur, the individual would need to consume an excessive number of calories. Since the adolescent's weight is appropriate for his height, it suggests that his caloric intake is likely balanced and not excessive.
suggesting that he is substituting food for unfilled needs in (option B) is incorrect because it, is speculative and may not be accurate without further assessment or evidence. It is important to avoid making assumptions about underlying psychological or emotional reasons for increased eating without more information.
stating that this is normal due to an increase in body mass during this time in (option C) is incorrect because it, is not necessarily applicable to the scenario. While it is true that adolescents experience growth and changes in body composition during this period, it does not directly explain the constant eating behaviour described.
suggesting that this behaviour is abnormal and indicative of possible future obesity in (option D) is incorrect because it, may be premature and unsupported based solely on the information provided. It is essential to avoid making predictions or assumptions about future health outcomes without proper evaluation.
By providing the parents with information about the caloric intake required for weight gain and reassuring them that their son's eating behaviour may be within a normal range, the nurse can address their concerns and provide accurate guidance. If the parents have further concerned or questions, it may be appropriate to refer them to a healthcare provider for a more comprehensive assessment.
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