A nurse is caring for a child who has a nosebleed. Which of the following actions should the nurse take?
Have the child sit with her head tilted forward and hold pressure on her nose for 10 min.
Place the child in a sitting position and tilt her head back.
Apply ice at the opening of the nares for 5 min and then re-check for bleeding.
Place the child in a supine position with a pillow under her head.
The Correct Answer is A
A. Have the child sit with her head tilted forward and hold pressure on her nose for 10 min. Tilting the head forward helps prevent blood from flowing down the throat and causing nausea or choking. Applying pressure to the nose for 10 minutes helps to stop the bleeding.
B. Place the child in a sitting position and tilt her head back. Tilted head back can cause blood to flow down the throat and potentially cause aspiration or choking. It's not recommended in managing nosebleeds.
C. Apply ice at the opening of the nares for 5 min and then re-check for bleeding. While cold compresses can help constrict blood vessels, direct pressure and maintaining a forward head position are more effective for stopping nosebleeds.
D. Place the child in a supine position with a pillow under her head. Supine position can cause blood to flow down the throat and is not recommended in managing nosebleeds due to the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Has your child had any diarrhea?" Diarrhea is not typically associated with glomerulonephritis.
B. "Have you noticed any rashes on your child?" Rashes are not typically associated with glomerulonephritis.
C. "Did your child sustain any injuries to the kidney area?" Direct kidney trauma is not a common cause of glomerulonephritis in children.
D. "Did your child recently complain of a sore throat?" Poststreptococcal glomerulonephritis (a common cause of acute glomerulonephritis in children) often follows a streptococcal throat or skin infection. Asking about a recent sore throat can provide important information about a possible streptococcal infection.
Correct Answer is D
Explanation
A. Maintain a saline-lock.Maintaining a saline lock is important for potential intravenous access, but it is not the most urgent priority compared to actions that directly monitor the child's condition and help manage the disease.
B. Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
C. A no-salt-added diet is important to help manage fluid retention and hypertension, which are common in acute glomerulonephritis. However, while important, it does not take immediate priority over assessing the child's fluid status.
D. Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action.
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