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
The term used to describe an abnormally increased convex angulation in the curvature of the thoracic spine, which appears as a "hump back" or rounded upper back, is kyphosis.
Kyphosis refers to an excessive forward rounding or curvature of the thoracic spine, leading to a visible hump-like appearance. It can result from various causes, including poor posture, congenital abnormalities, osteoporosis, or certain medical conditions.
ankylosis in (option A), refers to the abnormal fusion or immobility of a joint, typically due to inflammation or injury.
Lordosis, in (option C) refers to an excessive inward curvature of the lower back, causing the abdomen and buttocks to protrude.
, scoliosis in (option D), refers to an abnormal sideways curvature of the spine, typically in an "S" or "C" shape. It is different from kyphosis, which primarily affects the thoracic spine and results in a rounded upper back.
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.
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