The nurse in a school clinic is caring for a 7-year-old girl who comes in for epistaxis. The nurse will initiate which of the following interventions? (Select the 2 responses that apply)
Apply a heat pack to the bridge of the nose.
Lightly suction blood from nares and mouth.
Have the child tilt her head forward.
Have the child sit upright.
The Correct Answer is C
Choice A reason: Applying a heat pack to the bridge of the nose is not recommended as it may increase blood flow and worsen the bleeding.
Choice B reason: Lightly suctioning blood from nares and mouth is not typically necessary and could be uncomfortable for the child.
Choice C reason: This is one of the correct choices. Tilting the head forward prevents blood from flowing down the throat, which can cause nausea or vomiting.
Choice D reason: This is one of the correct choices. Sitting upright reduces blood pressure in the veins of the nose and may help slow the bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. The level of consciousness is the most direct and immediate indicator of brain function following an injury.
Choice B reason: Gross motor skill function is important but may not be the best immediate indicator of brain function.
Choice C reason: Pupil response is a good indicator of brain function but is part of a broader neurological assessment that includes the level of consciousness.
Choice D reason: Vital signs are important to monitor but do not directly indicate brain function like the level of consciousness does.
Correct Answer is D
Explanation
Choice A reason: While peer group acceptance is important, it is not the primary concern in this situation.
Choice B reason: Developing a sense of industry is part of Erikson's stages of psychosocial development but is not the primary nursing concern here.
Choice C reason: Whether the child can manage their own insulin and finger sticks is important, but safety is the primary concern.
Choice D reason: This is the correct choice. Ensuring the child's safety is paramount, as the school needs to be aware of the child's condition in case of a diabetes-related emergency.
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