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 C
Explanation
Hydrocephalus refers to a condition characterized by an abnormal accumulation ofcerebrospinal fluid (CSF) within the ventricles of the brain. In infants, hydrocephalus cancause the head to enlarge rapidly as a result of the increased pressure exerted by theaccumulatingfluid.Thisisknownas"rapidheadgrowth."Theincreasedintracranialpressurecanlead to irritabilityand poorappetite in infants.
The distended scalp veins are another common sign of hydrocephalus. As the fluidaccumulates,itputs pressureon thebloodvessels inthe brain,causingtheveinsin thescalptobecome morevisible and distended.
Cerebral palsy in (option A) is incorrect because is a neurological disorder that affects bodymovementandmusclecoordination,butitdoesnottypicallypresentwithrapid headgrowthordistended scalp veins.
Syndrome of inappropriate antidiuretic hormone (SIADH) in (option B) is incorrect becauseitisacondition characterized byexcessivesecretionofantidiuretichormone,leadingtofluidimbalance, but it does not usually cause rapid head growth or distended scalp veins. Reye'ssyndrome (D) is a rare condition that primarily affects the liver and brain, and it does nottypicallypresent with rapid headgrowthor distended scalp veins.
Therefore, based on the signs described, hydrocephalus (C) is the most likely disorder in thiscase.Itisimportantto seekmedicalattentionpromptlyforaproperdiagnosisand appropriatemanagementofhydrocephalus in infants.
Correct Answer is C
Explanation
Infants and children have open growth plates, also known as epiphyseal plates, at the ends of
their long bones. These plates are responsible for bone growth and are not fully fused until
the child reach skeletal maturity. Due to the presence of open growth plates, infants and
children are more prone to fractures because their bones are still developing and are less
dense than those of adults.
Their bones have less blood flow in (Option A) is incorrect because cchildren’s bones
actually have a greater blood flow compared to adults. This increased blood flow supports the
rapid growth and development of bones in children.
Growth occurs in children as a result of an increase in the number of muscle fibers in (option
B) is incorrect because ggrowth in children occurs primarily due to the elongation and
thickening of existing muscle fibres, not an increase in their number. This option inaccurately
suggests that children's muscles increase in fibber count to facilitate growth.
Because soft tissues are resilient in children, dislocations and spirals are less common than in
adults in (Option D is) incorrect. While soft tissues may be more resilient in children, it does
not mean that dislocations and sprains are less common than in adults. In fact, children's
ligaments and joint structures are still developing and may be more susceptible to injuries
such as sprains and dislocations compared to adults.
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