A nurse is creating a plan of care for a child who is awake and responsive following an acute head injury. Which of the following interventions should the nurse include?

Place the child in a room with bright fluorescent lighting.

Initiate seizure precautions for the child.

Use the COMFORT scale to rate the child's pain.

Suction the child's nares to determine the presence of fluid.

Answer and Explanation

The Correct Answer is B

A. Place the child in a room with bright fluorescent lighting.

This option is not appropriate because bright fluorescent lighting can be uncomfortable and potentially aggravate symptoms such as headache or sensitivity to light, which are common after a head injury. Therefore, it is not included in the plan of care.

B. Initiate seizure precautions for the child.

This intervention is appropriate because children with head injuries are at an increased risk of seizures. Seizure precautions may include ensuring a safe environment, such as padding the sides of the bed, removing any objects that could cause harm during a seizure, and closely monitoring the child's neurological status for signs of seizure activity.

C. Use the COMFORT scale to rate the child's pain.

While assessing and managing pain is important, the COMFORT scale may not be the most appropriate tool for evaluating pain in a child with a head injury. The nurse should use a pain assessment tool that is specifically designed for pediatric patients and is suitable for assessing pain in children with head injuries.

D. Suction the child's nares to determine the presence of fluid.

Suctioning the child's nares may be indicated if there are concerns about airway patency or respiratory secretions. However, it is not a routine intervention for all children with head injuries. The nurse should assess the child's respiratory status and use suctioning only if necessary based on clinical findings.

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Correct Answer is B

Explanation

A. The infant does not exhibit fear of strangers.

The infant does not exhibit fear of strangers is not a finding that the nurse should report to the provider, as this is a normal social behavior for a 6-month-old infant. Infants usually develop stranger anxiety between 8 and 12 months of age, when they become more aware of their surroundings and attachment figures.

B. The infant does not roll over from his abdomen to his back.

By 6 months of age, most infants can roll over in both directions— from their abdomen to their back and vice versa. The inability to roll over from abdomen to back may indicate a delay in gross motor skills development. This finding should be reported to the healthcare provider for further evaluation.

C. The infant does not pick up objects from the floor with his fingers.

By 6 months of age, infants typically begin to develop the ability to grasp and pick up objects using their fingers. This milestone is part of fine motor skills development. The inability to pick up objects from the floor with fingers may indicate a delay in fine motor skills and should be reported to the provider for further assessment.

D. The infant does not sit on the floor unsupported.

By 6 months of age, infants typically begin to develop the ability to sit unsupported for short periods. While some variability exists in when infants achieve this milestone, the inability to sit unsupported at 6 months may indicate a delay in gross motor skills development. This finding should be reported to the provider for further evaluation.

A. "Expect the medication to cause constipation for the first few days of therapy." B. "Take the medication at the same time each day." C. "This medication is used for short-term therapy until your symptoms improve." D. "Take this medication 1 hour before meals."

Correct Answer is B

Explanation

A. "Expect the medication to cause constipation for the first few days of therapy.": This statement is incorrect. Metformin commonly causes gastrointestinal side effects such as diarrhea, abdominal discomfort, and nausea, especially when therapy is initiated. Constipation is not typically associated with metformin use.

B. "Take the medication at the same time each day.": This is a correct instruction. It is important for the adolescent to take metformin at the same time each day to maintain consistent blood levels of the medication and optimize its effectiveness.

C. "This medication is used for short-term therapy until your symptoms improve.": This statement is incorrect. Metformin is typically used for long-term management of type 2 diabetes mellitus to help control blood sugar levels. It is not intended for short-term therapy.

D. "Take this medication 1 hour before meals.": This statement is incorrect. While metformin can be taken with meals to reduce gastrointestinal side effects, it is not necessary to take it specifically 1 hour before meals. It can be taken with meals or shortly after meals.

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A nurse is creating a plan of care for a child who is awake and responsive following an acute head injury. Which of the following interventions should the nurse include?

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