Exhibits
The parents are at the bedside and state that each parent thought the other parent was watching the child. They are not sure how long he was in the pool or how he might have fallen in. The temperature of the pool was cool as the temperature outside was about 64 °F (17.8 °C).
Placed a cervical collar with the assistance of the physician. The child's pulse is 121 beats/minute, the airway is patent, and there are no signs of any bleeding.
Review H and P, nurse's note, laboratory results, orders, and imaging studies. What complications should the nurse monitor for in the next 6 to 8 hours? Select all that apply.
Cerebral edema
Acute asphyxia
Hypertension
Respiratory distress
Hyperthermia
Subdural hemorrhage
Correct Answer : A,D
Choice A rationale: Hypoxic-ischemic injury from submersion can lead to delayed cerebral edema. Monitoring is critical as the brain's inflammatory response to the initial insult often peaks several hours after the event.
Choice B rationale: Asphyxia is the initial event that occurred in the pool. By the time the child is admitted to the pediatric floor, the asphyxiation event has passed; the nurse now monitors for its aftereffects.
Choice C rationale: Near-drowning victims are more likely to experience hypotension due to myocardial depression or shifting fluid balances. Hypertension is not a typical expected complication in the immediate post-submersion recovery period.
Choice D rationale: Aspiration of water interferes with surfactant production and damages alveolar membranes, leading to pulmonary edema or ARDS. Respiratory status can deteriorate rapidly 6 to 8 hours after the initial insult.
Choice E rationale: The child was in cool water with an outdoor temperature of 64°F, making hypothermia the primary concern. Hyperthermia is not expected unless a secondary infection or a thermregulation failure occurs much later.
Choice F rationale: The head CT scan was negative for bleeding. Without a significant traumatic impact or pre-existing condition, a subdural hemorrhage is not a standard complication resulting from a submersion injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Applying ice can cause vasoconstriction and potentially inhibit the let-down reflex. While it might temporarily firm the tissue, it does not effectively address the anatomical challenge of inverted nipples.
Choice B rationale: While a pump can help draw out a nipple or maintain supply, the immediate concern is the baby's inability to latch at the breast for a successful feeding session.
Choice C rationale: Offering formula as a first-line intervention can undermine the mother's breastfeeding goals and interfere with the establishment of her milk supply and the infant's natural sucking reflex.
Choice D rationale: A breast shield is a silicone device that fits over the nipple and areola, providing a firm, protruded surface for the infant to latch onto when nipples are flat.
Correct Answer is D
Explanation
Situation: Increasing confusion of the client.
The nurse should start by providing the current situation, which is the client's increasing confusion. This is crucial information as it indicates a change in the client's condition and may require immediate attention.
Background: Fall at home as reason for admission.
Next, the nurse should provide the background information, which includes the reason for admission, in this case, the fall at home. This helps the healthcare provider understand the context and potential contributing factors to the client's current condition. Assessment: Currently prescribed medications.
After providing the background, the nurse should discuss the assessment findings. In this case, it would be appropriate to mention the client's currently prescribed medications. This information can help the healthcare provider assess for any medication-related issues or interactions that could be contributing to the client's confusion.
Recommendation: Client's healthcare power of attorney.
Lastly, the nurse should provide the recommendation, which in this case is the client's healthcare power of attorney. This information is important as it identifies the designated decision-maker for the client's healthcare decisions and can assist the healthcare provider in involving the appropriate person in the care planning process.
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