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

Answer and Explanation

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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Correct Answer is B

Explanation

A) Document intake and output:

Documenting intake and output is an important nursing task, but it is not the top priority in a suspected case of bacterial meningitis. Timely administration of antibiotics to treat the infection takes precedence over documentation of intake and output.

B) Administer antibiotics when available.

Explanation:

Bacterial meningitis is a serious and potentially life-threatening infection of the membranes covering the brain and spinal cord. Rapid administration of antibiotics is crucial to effectively treat the infection and prevent its spread. Delay in antibiotic administration can lead to worsening symptoms and complications. Therefore, getting the appropriate antibiotics to the child as soon as they are available is the nurse's priority.

C) Reduce environmental stimuli:

Reducing environmental stimuli can be helpful in managing symptoms and providing comfort to the child with meningitis, but it is not the priority action. The immediate concern in a suspected case of bacterial meningitis is to treat the infection.

D) Maintain seizure precaution:

While maintaining seizure precautions is important, especially if the child has a history of seizures, it is not the top priority in a suspected case of bacterial meningitis. Administering antibiotics to treat the infection and prevent its progression is the primary concern.

A. Position the child laterally B. Use a padded tongue blade. C. Attempt to stop the seizure D. Restrain the child's arms,

Correct Answer is A

Explanation

A. Position the child laterally

Explanation: When a child is experiencing a seizure, it's important to ensure their safety and prevent injury. Positioning the child laterally, also known as the recovery position, helps keep the airway clear and allows any fluids to drain from the mouth, reducing the risk of aspiration. It also helps prevent the child from choking on saliva or vomit.

The other options are not appropriate actions during a seizure:

B. Using a padded tongue blade is not recommended during a seizure. Placing objects in the mouth during a seizure can lead to injury, including damage to the teeth, jaw, or airway.

C. Attempting to stop the seizure is not within the nurse's control. Seizures are caused by abnormal electrical activity in the brain and should not be interrupted forcefully. Instead, the focus should be on ensuring the child's safety and managing the situation until the seizure stops on its own.

D. Restraining the child's arms is not advisable during a seizure. Restraining can cause harm and increase the risk of injury to the child or others involved. It's important to allow the seizure to run its course while protecting the child from harm.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Correct Answer is B

Explanation

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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