Exhibits
Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.
Course breath sounds
Decreased level of consciousness
Seizure activity
Irritability
Bradycardia
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"},"E":{"answers":"B"}}
Course breath sounds - Respiratory Distress
Decreased level of consciousness - Cerebral Edema
Seizure activity - Cerebral Edema
Irritability - Both (Can be associated with both cerebral edema and respiratory distress)
Bradycardia - Cerebral Edema
Rationale:
Course breath sounds - Respiratory Distress
Course breath sounds could indicate the presence of secretions or fluid in the airways, which is a sign of respiratory distress. It suggests that there might be a problem with the airway or lung function.
Decreased level of consciousness - Cerebral Edema
A decreased level of consciousness can be a sign of cerebral edema, which is the swelling of the brain due to increased intracranial pressure. This can lead to changes in the child's mental status and responsiveness.
Seizure activity - Cerebral Edema
Seizure activity can be a manifestation of cerebral edema. Swelling and pressure in the brain can irritate brain tissue and lead to seizures.
Irritability - Both (Can be associated with both cerebral edema and respiratory distress) Irritability can be seen in both cerebral edema and respiratory distress. In cerebral edema, the pressure on the brain can cause discomfort and irritability. In respiratory distress, the child may be uncomfortable due to difficulty breathing.
Bradycardia - Cerebral Edema
Bradycardia (slow heart rate) can be associated with increased intracranial pressure and cerebral edema. It can be a response to the pressure on the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
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.
Correct Answer is ["400"]
Explanation
To calculate the mL/hr rate for the infusion pump, we can use the following formula: mL/hr = (Total volume to be infused in mL) / (Time in hours)
In this case, the total volume to be infused is 200 mL, and the infusion time is 30 minutes, which is equal to 0.5 hours.
mL/hr = 200 mL / 0.5 hours mL/hr = 400 mL/hr
Therefore, the nurse should program the infusion pump to deliver 400 mL/hr.
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