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
The nurse's best response to the parents of a 10-year-old child newly diagnosed with type 1
diabetes mellitus, who are concerned about the child's continued participation in soccer, is to
reassure them that it is generally safe for the child to play sports such as soccer unless the
weather is too hot.
Regular physical activity, including participation in sports, is generally encouraged for
children with type 1 diabetes as long as certain precautions are taken. It is important for the
child to have a well-managed diabetes management plan in place, which may include
monitoring blood sugar levels before, during, and after physical activity, adjusting insulin
doses as necessary, and having appropriate snacks available to maintain blood sugar levels.
Option B, suggesting the swim team as an alternative to soccer, may be a viable option if the
child or parents prefer swimming or if the child has specific concerns related to soccer.
However, it is not the best response to the parents' concern about the child's continued
participation in soccer.
Option C, recommending an extra carbohydrate snack before soccer practice, is a valid
suggestion to help maintain the child's blood sugar levels during physical activity. However,
it should be part of a comprehensive diabetes management plan and not the sole response to
the parents' concern.
Option D, encouraging intellectual activity rather than participation in sports, is not
appropriate as physical activity is generally beneficial for children with type 1 diabetes, as
long as appropriate precautions are taken.
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.

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