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 C
Explanation
The correct answer is choice C. Observe both lower extremities for redness and swelling.
Choice A rationale:
Palpating all peripheral pulse points for volume and strength is important for assessing circulation, but it does not directly evaluate the effectiveness of intermittent pneumatic compression (IPC) devices.IPC devices are primarily used to prevent deep vein thrombosis (DVT) and improve venous return, so monitoring for signs of DVT is more relevant.
Choice B rationale:
Monitoring the amount of drainage from the client’s incision is crucial for assessing wound healing and detecting potential infections, but it is not related to the effectiveness of IPC devices.
Choice C rationale:
Observing both lower extremities for redness and swelling is the most important assessment for evaluating the effectiveness of IPC devices. Redness and swelling can be signs of DVT, which IPC devices are designed to prevent.Therefore, this assessment directly measures whether the devices are functioning as intended.
Choice D rationale:
Evaluating the client’s ability to use an incentive spirometer is important for preventing postoperative pulmonary complications, but it does not assess the effectiveness of IPC devices.
Correct Answer is B
Explanation
A.Protect the site from getting wet during bathing. While it is important to avoid prolonged soaking, gentle rinsing with water is usually allowed. Complete avoidance of water is not typically necessary.Gentle bathing is important for hygiene.
B.Gently patting the skin dry after rinsing with water is a good practice as it helps to minimize friction and irritation to the sensitive skin. Rubbing or scrubbing the skin should be avoided.
C. Applying moisturizers to prevent dry skin can be beneficial for overall skin health, but it is important to consult with the healthcare team and follow specific instructions regarding the use of moisturizers during radiation therapy. Certain types of moisturizers or creams may interfere with the radiation treatment or cause skin irritation. Frequent application is not always necessary. Over-hydration can soften the skin and increase vulnerability.
D.Using a sponge to debride the affected area is not recommended during radiation therapy. The skin in the radiation treatment field is already sensitive and prone to damage, and using a sponge for debridement can further traumatize the skin. It is important to avoid any abrasive or rough handling of the treated skin.
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