A nurse is planning care for a child who is unresponsive and has increased intracranial pressure. Which of the following actions should the nurse take?

Schedule routine oral suctioning

Pad the side rails of the bed.

Obtain isolation supplies

Place the child in Trendelenburg position

Answer and Explanation

The Correct Answer is B

A. Schedule routine oral suctioning: Suctioning can increase intracranial pressure and should be performed only when necessary, using short, gentle passes. Routine suctioning is not recommended for a child with increased ICP, as it can exacerbate neurological injury.

B. Pad the side rails of the bed: An unresponsive child is at high risk for injury from involuntary movements or seizures. Padding the side rails helps prevent trauma and is a key safety intervention in children with increased intracranial pressure, making it the priority action in this scenario.

C. Obtain isolation supplies: Isolation precautions are only needed if the child has a contagious condition. Increased intracranial pressure does not automatically indicate a risk of infection transmission, so isolation supplies are not immediately necessary.

D. Place the child in Trendelenburg position: Trendelenburg positioning (head-down) can further increase intracranial pressure and is contraindicated. Children with elevated ICP should be positioned with the head of the bed elevated to promote venous drainage and reduce pressure.

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Correct Answer is A

Explanation

A. A 24-year-old male who has a casted femur fracture: Long bone fractures, particularly of the femur, are the most common cause of fat embolism syndrome (FES). Fat globules can enter the bloodstream from the bone marrow, leading to respiratory, neurologic, and dermatologic manifestations. Young adults are at higher risk due to the frequency of high-energy trauma.

B. A 10-year-old female who has an ulnar fracture in an external fixator: FES is rare in small bone fractures such as the ulna, especially in children. The risk is minimal because less marrow fat is released into circulation compared with long bones like the femur.

C. A 45-year-old male who has multiple rib fractures: Rib fractures carry a low risk for FES because they involve flat bones with less marrow fat. The primary complications are respiratory in nature, such as pneumothorax or pulmonary contusion.

D. A 62-year-old female who has vertebral fractures due to osteoporosis: Vertebral fractures in older adults rarely result in FES because the marrow fat released is minimal, and low-energy trauma is usually involved. Other complications, such as spinal cord injury or chronic pain, are more likely.

A. Hallucinations B. Аgnosia C. Bradycardia D. Aphasia

Correct Answer is A

Explanation

A. Hallucinations: Hallucinations are common in clients experiencing delirium, especially when it is related to a febrile or acute medical illness. They can involve seeing or hearing things that are not present and reflect the acute cognitive disturbances characteristic of delirium.

B. Agnosia: Agnosia is the inability to recognize familiar objects, people, or sounds and is more commonly associated with neurodegenerative disorders such as dementia rather than acute delirium. It is not a typical finding in febrile-induced delirium.

C. Bradycardia: Delirium related to a febrile illness usually does not cause bradycardia. Vital signs are more likely to show tachycardia due to fever or systemic infection. Bradycardia would suggest a different cardiac or medication-related issue.

D. Aphasia: Aphasia, the impairment of language expression or comprehension, is generally linked to stroke or localized brain injury. It is not a common manifestation of acute delirium caused by a febrile illness.

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A nurse is planning care for a child who is unresponsive and has increased intracranial pressure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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