The nurse is triaging several children as they present to the emergency room after a school bus accident. Which child requires the most immediate intervention by the nurse?
A 12-year-old reporting neck, arm, and lower back discomfort.
An 8-year-old with a full leg air splint for a possible broken tibia.
A 6-year-old with multiple superficial lacerations of all extremities.
An 11-year-old with a headache, nausea, and projectile vomiting.
The Correct Answer is D
A. A 12-year-old reporting neck, arm, and lower back discomfort:
- This child is reporting discomfort, which is concerning, but it doesn't indicate an immediate life-threatening condition. However, a thorough assessment is needed to rule out any serious injuries, especially to the spine.
B. An 8-year-old with a full leg air splint for a possible broken tibia:
- While a possible broken tibia requires attention, it is not as immediately critical as symptoms such as projectile vomiting. Splinting can help stabilize the limb, but it is not an emergency that requires immediate attention compared to potential neurological issues.
C. A 6-year-old with multiple superficial lacerations of all extremities:
- Superficial lacerations, although they require care, are generally not immediately life-threatening. The child needs appropriate wound care and assessment for any deeper injuries, but this can be addressed in a timely manner without immediate urgency.
D. An 11-year-old with a headache, nausea, and projectile vomiting:
- This is the most concerning presentation among the options. Headache, nausea, and projectile vomiting could be indicative of a severe head injury, and these neurological symptoms require urgent evaluation to assess for conditions such as a concussion, intracranial bleed, or increased intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Fever increases fluid loss through perspiration.
Increased respiratory rate can lead to increased fluid loss through evaporation. Increased nasal secretions can result in fluid loss.
High oxygen flow can cause drying of the mucous membranes and increase fluid requirements.
The following findings do not necessarily indicate increased fluid requirements: Blood pressure alone does not indicate increased fluid requirements.
Oxygen saturation within the normal range does not indicate increased fluid requirements.
Although urine output is important to assess hydration status, 12 mL of urine may not necessarily indicate increased fluid requirements.
Heart rate alone does not indicate increased fluid requirements.
Correct Answer is B
Explanation
In this situation, the client has a fingerstick glucose level of 35 mg/dL (1.94 mmol/L) and is alert but diaphoretic. The charge nurse should take the following action:
Give the client a glass of orange juice.
A glucose level of 35 mg/dL (1.94 mmol/L) is considered significantly low (hypoglycemia), and the client's symptoms of diaphoresis indicate that the low glucose level is likely causing the symptoms. Providing the client with a glass of orange juice or another source of fast-acting carbohydrate is appropriate to quickly raise the blood sugar level and alleviate the symptoms of hypoglycemia.
Collecting a blood sample for hemoglobin A1c (HbA1c) is not necessary in this acute situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is used to assess long-term glycemic control in clients with diabetes. It does not provide immediate information or guide immediate interventions for acute hypoglycemia.
Notifying the healthcare provider is not the first action to take in this situation. The client's low glucose level can be promptly addressed by administering a source of fast-acting carbohydrate, such as orange juice. If the client's symptoms persist or worsen despite appropriate intervention, or if there are other concerning factors, then notifying the healthcare provider would be appropriate.
Assessing the client for polyuria (excessive urination) and polyphagia (excessive hunger) is important in the overall management of diabetes, but it is not the immediate action to take in this acute situation of hypoglycemia. The priority at this time is to address the low blood sugar level and relieve the client's symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.