The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

Side-lying with the head slightly elevated.

Standing with the head leaning backward.

Sitting up and leaning forward.

Supine with the legs raised.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- This position is not ideal for managing a nosebleed because it does not promote drainage and may lead to blood flowing down the throat.
B)   Incorrect- Leaning the head backward can cause blood to flow down the throat and may lead to choking or aspiration.
C)   Correct- Placing the child in a sitting position and leaning forward helps prevent blood from flowing down the back of the throat, which can lead to choking or aspiration. Leaning forward allows the blood to drain out through the nostrils.
D)   Incorrect- Placing the child in a supine position with raised legs is not recommended for managing a nosebleed, as it may lead to blood flowing down the throat.

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Correct Answer is A

Explanation

Assessing the client's level of consciousness involves observing their responsiveness, orientation, and ability to follow commands. If the client is unresponsive or exhibits any signs of altered consciousness, the nurse should immediately activate the emergency response system and begin resuscitative measures, such as administering oxygen and initiating cardiopulmonary resuscitation (CPR) if necessary.

Once the client's level of consciousness is established and the emergency response system has been activated if necessary, the nurse can proceed to assess the depth of the slashes, estimate the amount of blood loss, and find the object used to cause the injuries. These assessments will provide important information about the extent and severity of the client's injuries, which will guide subsequent interventions.

A. Disturbed Body Image. B. Interrupted Family Processes. C. Imbalanced Nutrition: less than body requirements. D. Noncompliance with treatment regimen.

Correct Answer is C

Explanation

less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications.

Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

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The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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