The nurse is caring for a 10-year-old who has an acute head injury, has a pediatric Glasgow coma score of 9. and is unconscious. Which interventions should the nurse include in the child's care plan?
Elevate the head of the bed 15 to 30 degrees with head maintained a midline position.
Maintain an active stimulating environment
Perform active chest percussion and suctioning every 1 to 2 hours.
Instruct child on preforming active range of motion
The Correct Answer is A
A. Elevate the head of the bed 15 to 30 degrees with head maintained a midline position.
Correct Explanation: This intervention is appropriate for a child with an acute head injury.
Explanation: Elevating the head of the bed helps reduce intracranial pressure by facilitating venous drainage from the head. However, it's important to keep the head in a midline position to prevent neck flexion, which can obstruct venous flow. Elevating the head 15 to 30 degrees is a standard approach for managing intracranial pressure in patients with head injuries.
B. Maintain an active stimulating environment.
Incorrect Explanation: Maintaining an active stimulating environment is not suitable for a child with an acute head injury.
Explanation: A child with an acute head injury should be in a quiet and calm environment. Overstimulation can worsen the condition by increasing intracranial pressure. It's important to minimize stimuli to allow the brain to heal.
C. Perform active chest percussion and suctioning every 1 to 2 hours.
Incorrect Explanation: Chest percussion and suctioning are not relevant interventions for an acute head injury.
Explanation: Active chest percussion and suctioning are typically used to manage respiratory conditions. While maintaining good respiratory function is important for overall patient care, it's not a primary intervention for an unconscious child with a head injury.
D. Instruct child on performing active range of motion.
Incorrect Explanation: Instructing the child on performing active range of motion is not appropriate for an unconscious child with a head injury.
Explanation: An unconscious child cannot actively perform range of motion exercises. Additionally, it's not a priority intervention in the acute phase of head injury management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "Limit fluid intake during mealtime":
Limiting fluid intake during meals is not a standard practice for managing type 1 diabetes. Proper hydration is important for overall health, and fluids should be consumed as needed.
B) "Notify the provider if blood glucose levels are over 350 milligrams/deciliter":
Blood glucose levels over 350 mg/dL can indicate hyperglycemia, which requires prompt attention. High blood glucose levels can lead to complications if not addressed promptly. Contacting the healthcare provider is an appropriate step. However, consistentBlood Glucose Levels Above 240 mg/dL (13.3 mmol/L) or presence of symptoms likefrequent urination, thirst, blurry vision, or fatigue) are concerning. The clientshould have contacted the health care provider by this point.
C) "Test the urine for ketones":
Testing urine for ketones is an important instruction. Ketones are produced when the body breaks down fat for energy, often in the absence of sufficient insulin. High ketone levels can indicate diabetic ketoacidosis (DKA), a serious complication. Regular ketone testing, especially during illness or high blood glucose levels, helps monitor for DKA.
D) "Withhold insulin dose if feeling nauseous":
This instruction is not accurate. Nausea could be a sign of various conditions, including illness. Insulin should not be withheld without consulting a healthcare provider. Managing insulin doses appropriately is crucial to maintaining blood glucose control
Correct Answer is A
Explanation
A. Levothyroxine
Correct Answer: Levothyroxine should be administered before breakfast.
Explanation: Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. It needs to be taken on an empty stomach, at least 30 minutes before eating, to ensure proper absorption. Food can interfere with its absorption, especially foods containing calcium, iron, and fiber.
B. Digoxin
Incorrect Explanation: Digoxin does not need to be administered before breakfast.
Explanation: Digoxin is a medication used to treat heart conditions like congestive heart failure and atrial fibrillation. It doesn't have specific instructions regarding administration in relation to meals. It's important to administer digoxin consistently at the same time every day, but it doesn't need to be taken specifically before or after breakfast.
C. Divalproex
Incorrect Explanation: Divalproex does not need to be administered before breakfast.
Explanation: Divalproex is used to treat conditions like epilepsy and bipolar disorder. It can be taken with or without food. While taking it with food might reduce the likelihood of stomach upset, there's no requirement to take it specifically before breakfast.
D. Mycostatin Mouthwash
Incorrect Explanation: Mycostatin mouthwash is not related to breakfast timing.
Explanation: Mycostatin is an antifungal medication used to treat fungal infections in the mouth (oral thrush). Its administration is not linked to meal times. It's typically swished around in the mouth and then swallowed or spit out, depending on the specific instructions provided by the healthcare provider.
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