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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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A) Incorrect- Genetically inherited disorders of family members: While a family history of certain disorders might provide some insight, it is not typically the primary cause of elevated serum magnesium levels in an older adult.
B) Correct- Elevated serum magnesium levels are commonly associated with chronic laxative use, especially those containing magnesium-based compounds. Laxatives can lead to excessive magnesium intake, causing hypermagnesemia.
C. Incorrect- Smoking is not a common cause of elevated serum magnesium levels.

D. Incorrect- While dietary sources can contribute to magnesium intake, chronic laxative use is a more likely cause in this context.

A. Encourage the use of ice on the areola. B. Teach about the use of a breast pump. C. Offer supplemental formula feedings. D. Recommend using a breast shield.

Correct Answer is B

Explanation

The correct answer is Choice B.

Choice A rationale: Ice application induces vasoconstriction, which reduces swelling but does not evert inverted nipples. This action does not address the primary issue of nipple inversion preventing adequate latch.

Choice B rationale: Breast pump use creates negative pressure, drawing out the nipple. This eversion facilitates latching by providing a more prominent nipple for the infant's oral cavity to grasp effectively.

Choice C rationale: Supplemental formula feedings provide nutrition, but do not resolve the latching difficulty caused by inverted nipples. This can interfere with the establishment of the mother's milk supply.

Choice D rationale: Breast shields can aid latching, but they are most effective when used in conjunction with nipple eversion techniques. They do not directly address the underlying problem of inverted nipples.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse discovers that an older client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Correct Answer is B

Explanation

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement?

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond?

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst?

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