A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
Insomnia
Irritability
Diarrhea
Hypothermia
The Correct Answer is B
Rationale:
A) Insomnia is a sleep disorder and is not typically associated with head injuries unless there is a concurrent neurological complication.
B) Irritability can be a sign of increased intracranial pressure following a head injury and should be promptly reported for further evaluation.
C) Diarrhea is not a common manifestation of head injuries and would not typically be included in monitoring and reporting instructions.
D) Hypothermia is not typically associated with head injuries unless there is a severe injury with shock, and it is not a common manifestation requiring monitoring in the acute phase of head injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Monitoring capillary refill of the casted extremity is crucial for assessing circulation and ensuring there are no complications such as compartment syndrome.
B. While supporting the cast correctly is important, it is not the priority immediately following the application.
C. Examining the skin at the cast edges is important, but it is not the priority immediately following the application.
D. Instructing the child not to put anything inside the cast is important, but it is not the priority immediately following the application.
Correct Answer is D
Explanation
Rationale:
A) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.
B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.
C) A respiratory rate of 40/min is within the normal range for an infant.
D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.
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