The practical nurse (PN) is caring for a 3-month-old infant with a head injury who had a seizure episode. The infant has a high-pitched cry and is irritable. The caregiver reports that the infant rolled over and fell onto the carpeted floor. Which action should the PN take?
Obtain a heel stick glucose.
Report injury details to the charge nurse.
Initiate strict intake and output measurements.
Swaddle the infant in a blanket.
The Correct Answer is B
The PN should report the injury details to the charge nurse. This is important because the charge nurse needs to be aware of any changes in the patient's condition and can help determine the appropriate course of action. The other options are not the most appropriate actions for the PN to take in this situation.
Obtaining a heel stick glucose (A) may be necessary if hypoglycemia is suspected, but it is not the most immediate concern.
Initiating strict intake and output measurements (C) may be necessary for monitoring fluid balance, but it is not the most immediate concern.
Swaddling the infant in a blanket (D) may provide comfort, but it does not address the underlying issue of the head injury and seizure episode.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Repeated visits to multiple emergency departments for various injuries or complaints can be a red flag for possible child abuse. The other options may indicate other issues or concerns, but they do not provide as much reason to suspect child abuse as the history of repeated visits to different emergency departments. It is important for healthcare providers to remain vigilant for signs of child abuse and to report any suspicions to the appropriate authorities.
Correct Answer is A
Explanation
During pregnancy, it is important for the client to consume a balanced and nutritious diet that includes adequate protein, vitamins, and minerals. However, clients with nausea and vomiting may have difficulty tolerating certain foods, particularly those that are high in fat or spicy. Cheeseburgers and French fries are typically high in fat and can exacerbate nausea, making them a poor choice for a client with this symptom.
Baked chicken with rice and pasta with steamed vegetables are both healthier options that can provide the client with adequate nutrition.
Baked potato chips and lemonade may be a suitable snack for some clients, but the high salt content of the chips may exacerbate fluid retention, which can be a concern for clients with pyelonephritis. The PN should encourage the client to choose healthier options and avoid foods that are likely to exacerbate her symptoms.
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