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 A
Explanation
Intussusception is a medical condition where a portion of the intestine telescopes into an adjacent section, causing an obstruction. This obstruction can affect the normal passage of stool through the intestine.
In intussusception, the obstructed intestine can lead to the development of blood and mucus within the stool, giving it a characteristic appearance described as "currant jelly." The stool may contain a combination of blood, mucus, and faecal matter, resembling the colour and consistency of currant jelly.
loose, foul-smelling stools in (option) is incorrect because it, is not specific to intussusception and can be associated with various gastrointestinal conditions.
hard stools positive for guaiac in (option C) is incorrect because it, is not typical of intussusception. Hard stools and positive guaiac test results are more commonly associated with constipation or other conditions affecting the lower gastrointestinal tract.
ribbon-like stools, in (option D) is incorrect because it may be seen in conditions like colorectal cancer or other obstructive disorders. However, it is not a specific characteristic of intussusception.
In the context of intussusception, the presence of "currant jelly" stools is considered a significant sign and should prompt immediate medical attention. Intussusception is a medical emergency and requires prompt diagnosis and treatment.
Correct Answer is C
Explanation
A sign of increased intracranial pressure (ICP) in a 10-year-old child is a headache. Headache is a common symptom associated with increased pressure within the cranial cavity. It can be a result of various conditions that cause elevated intracranial pressure, such as brain tumours, intracranial haemorrhage, hydrocephalus, or brain trauma. The headache may be described as persistent, worsening, or accompanied by other symptoms such as nausea, vomiting, or changes in neurological status.
tachypnoea (rapid breathing), in (option A) is incorrect because it is not a specific sign of increased intracranial pressure. It can be seen in various conditions, including respiratory and cardiovascular disorders, anxiety, or physical exertion.
bulging fontanel in (option B) is incorrect because it, is more commonly observed in infants and is not typically seen in older children. The fontanelles (soft spots) on an infant's skull normally close by the age of 18-24 months.
an increase in head circumference in (option D) is incorrect because it, may be a sign of increased intracranial pressure in infants. However, in a 10-year-old child, the fontanelles are typically closed, and head circumference growth is not a reliable indicator of increased intracranial pressure
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