A child with a brain tumor has a decreased respiratory hate and is less responsive to verbal commands than he was when the nurses assessed the client the previous hour. What should the nurse do next?
Raise the head of the bed
Notify the health care provider (HCP)
Obtain an oximeter reading
Implement seizure precautions
The Correct Answer is B
A. Raising the head of the bed may help with respiratory effort but does not address the underlying issue of decreased responsiveness. Immediate assessment and intervention are necessary.
B. Notifying the healthcare provider is critical as the child’s decreased responsiveness and respiratory rate indicate a potential deterioration in condition that requires prompt medical evaluation.
C. While obtaining an oximeter reading can provide useful information about oxygenation, the priority is to notify the HCP about the change in the child's neurological status.
D. Implementing seizure precautions is important for a child with a brain tumor, but the immediate concern is the change in responsiveness, necessitating HCP notification first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Positioning for comfort is a common intervention during a vaso-occlusive crisis to alleviate pain.
B. Restricting fluid intake is contraindicated in vaso-occlusive crisis; hydration is crucial to help reduce sickling and improve circulation.
C. Avoiding strain on painful joints is appropriate to prevent exacerbating pain and potential damage.
D. Applying nasal oxygen at 2 liters may be indicated to ensure adequate oxygenation, especially if the child is experiencing any respiratory distress.
Correct Answer is B
Explanation
A. Raising the head of the bed may help with respiratory effort but does not address the underlying issue of decreased responsiveness. Immediate assessment and intervention are necessary.
B. Notifying the healthcare provider is critical as the child’s decreased responsiveness and respiratory rate indicate a potential deterioration in condition that requires prompt medical evaluation.
C. While obtaining an oximeter reading can provide useful information about oxygenation, the priority is to notify the HCP about the change in the child's neurological status.
D. Implementing seizure precautions is important for a child with a brain tumor, but the immediate concern is the change in responsiveness, necessitating HCP notification first.
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