A nurse at an urgent care clinic is caring for a child who hit her head on the playground at school 30 minutes ago. Which of the following findings is the nurse's priority?
2 cm (0.8 in) scalp laceration.
Nasal discharge negative for glucose.
Asymmetric pupils.
Negative Babinski reflex.
The Correct Answer is C
Choice A rationale:
A 2 cm scalp laceration, while a concern, is not the nurse's priority in this scenario. The child's head injury could potentially be serious, but priority should be given to neurological assessments and signs of increased intracranial pressure.
Choice B rationale:
Nasal discharge negative for glucose is not indicative of a major issue in this context. While cerebrospinal fluid (CSF) leaking from the nose after head trauma is a concern, it is not mentioned in this scenario, and this choice does not take precedence over other neurological signs.
Choice C rationale:
This is the correct answer. Asymmetric pupils can be a sign of a serious neurological issue, such as a brain injury or increased intracranial pressure. It requires immediate attention and further evaluation to assess the child's neurological status and determine the extent of the injury.
Choice D rationale:
A negative Babinski reflex is a normal finding in this context and does not require immediate priority attention. The Babinski reflex is typically present in infants and disappears as the child grows older. Its absence is expected in older children and adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Acute otitis media is not a risk factor for physical maltreatment. It's an ear infection and does not directly contribute to the risk of physical abuse. The child's medical history should be assessed for factors that are more closely related to abuse.
Choice B rationale:
Myopia, or nearsightedness, is also not a risk factor for physical maltreatment. Myopia is a visual impairment and is not related to the risk of abuse. The nurse should focus on identifying factors that might indicate an increased likelihood of abuse.
Choice C rationale:
Prematurity can be a risk factor for various health issues in a child, but it is not directly linked to physical maltreatment. While preterm infants might have unique medical needs, being born prematurely does not inherently increase the risk of physical abuse.
Choice D rationale:
Correct Answer. Being adopted can be considered a potential risk factor for physical maltreatment. Children who are adopted might face certain challenges related to attachment, identity, and adjustment. It's important for healthcare providers to be vigilant and assess the child's situation comprehensively to ensure their safety and well-being.
Correct Answer is C
Explanation
Choice A rationale:
This medication can cause ringing in the ears (Choice A) is not a common side effect of amoxicillin. Ringing in the ears (tinnitus) is not typically associated with the use of this antibiotic.
Choice B rationale:
This medication can cause muscle pain (Choice B) is not a common side effect of amoxicillin. Muscle pain is not among the usual adverse reactions associated with its use.
Choice C rationale:
This medication can cause loose stools (Choice C) is a relevant side effect of amoxicillin. Antibiotics, including amoxicillin, can disrupt the normal balance of gut bacteria, potentially leading to gastrointestinal disturbances such as diarrhea or loose stools.
Choice D rationale:
This medication can cause blurred vision (Choice D) is not a common side effect of amoxicillin. Blurred vision is not a typical adverse effect associated with the use of this antibiotic.
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