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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Dry mouth: Dry mouth is not a common adverse effect of cefazolin. It is more commonly associated with other medications, such as anticholinergic drugs. While dry mouth may be uncomfortable, it is not typically considered a serious adverse effect of cefazolin that requires immediate reporting.
B. Constipation: Constipation is also not a common adverse effect of cefazolin. It is more commonly associated with other medications, dietary factors, or underlying medical conditions. Similar to dry mouth, constipation is not typically considered a serious adverse effect of cefazolin that requires immediate reporting.
C. Back pain: Back pain is not a common adverse effect of cefazolin. While musculoskeletal adverse effects can occur with some antibiotics, back pain is not typically associated with cefazolin. However, if severe or persistent back pain occurs, it should be reported to the healthcare provider for evaluation.
D. Urticaria: Urticaria, also known as hives, is a potential adverse effect of cefazolin and other antibiotics. It is characterized by raised, itchy welts on the skin and can be a sign of an allergic reaction. Urticaria should be reported to the healthcare provider immediately, as it may indicate a serious allergic reaction requiring prompt medical attention.
Correct Answer is B
Explanation
A. Coarctation of the aorta
Coarctation of the aorta involves a narrowing of the aorta, leading to decreased blood flow to the lower body. It is not associated with increased pulmonary blood flow.
B. Patent ductus arteriosus
Patent ductus arteriosus (PDA) is a congenital heart defect where the ductus arteriosus, a fetal blood vessel that usually closes shortly after birth, remains open. This allows blood to flow from the aorta into the pulmonary artery, increasing pulmonary blood flow. Therefore, option B is correct.
C. Tetralogy of Fallot
Tetralogy of Fallot is a congenital heart defect characterized by four abnormalities, including a ventricular septal defect (VSD), pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta. While it can lead to cyanosis due to right-to-left shunting, it is not primarily associated with increased pulmonary blood flow.
D. Tricuspid atresia
Tricuspid atresia involves the absence of the tricuspid valve, leading to a lack of direct blood flow from the right atrium to the right ventricle. It usually presents with decreased pulmonary blood flow rather than increased pulmonary blood flow.
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