Exhibits
Review H and P, nurse's note, laboratory results, prescriptions, and imaging studies.
What complications should the practical nurse (PN) monitor for in the next 6 to 8 hours? Select all that apply.
Subdural hemorrhage
Respiratory distress
Hyperthermia
Cerebral edema
Acute asphyxia
Hypertension
Correct Answer : B,D,E
A. Subdural hemorrhage
The head CT was negative for bleeding or edema, making a subdural hemorrhage unlikely.
B. Respiratory distress
Given the history of drowning and the current signs of respiratory acidosis (pH 7.31, PaCO2 51), the child is at high risk for respiratory complications, including distress.
C. Hyperthermia
Hyperthermia is not a typical immediate complication following drowning in cool water, and the current body temperature of the child is within the normal range.
D. Cerebral edema
Although the initial CT scan is negative for edema, secondary cerebral edema can develop hours after the incident, especially in cases of significant hypoxemia.
E. Acute asphyxia
The initial incident of drowning and the resultant hypoxemia (as indicated by abnormal blood gases) place the child at risk for complications related to acute asphyxia.
F. Hypertension
The child's blood pressure is currently within normal limits, and hypertension is not a common immediate complication following drowning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Extending progressive ambulation over one week is important but not the most critical instruction. Postoperative mobility is generally encouraged in a gradual manner, but it is not as urgent as managing specific activity restrictions.
B. Notifying the clinic if the child begins bedwetting is not typically a primary concern immediately following surgery for cryptorchidism. Bedwetting is not directly related to the surgical procedure or its common postoperative concerns.
C. Restricting the child from playing on riding toys is the most important instruction for preventing complications. Riding toys can be a safety risk due to potential trauma to the surgical site and could cause harm during the recovery period.
D. Supervising toileting to prevent picking at sutures is relevant but less critical compared to the need to restrict potentially harmful activities. While important, it is a secondary concern compared to overall activity restrictions.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}
Explanation
Coarse breath sounds are typically associated with respiratory distress, indicating fluid or secretions in the airways.
Irritability can be a sign of both cerebral edema and respiratory distress as it may stem from hypoxia or increased intracranial pressure.
Seizure activity is more specifically related to cerebral edema, which can increase intracranial pressure and provoke seizures.
Decreased level of consciousness can occur in both conditions: cerebral edema (due to increased intracranial pressure) and respiratory distress (due to hypoxia).
Bradycardia is more indicative of cerebral edema, especially when associated with increased intracranial pressure and resultant autonomic dysregulation.
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