When measuring a 6-month-old baby in the hospital for seizures, the nurse obtains a head circumference that is up 1 cm from the last measurement one week ago. The nurse re-measures and gets the same number What is the best next step?

Assume you made a mistake and report out the same head circumference as the before

Take Vital Signs

Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure

Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.

Answer and Explanation

The Correct Answer is C

A. Assume you made a mistake and report out the same head circumference as before.

Incorrect Explanation: Assuming a mistake without taking proper action might not be the best approach.

Explanation: While it's good to consider the possibility of human error, healthcare professionals should prioritize accurate measurements and follow appropriate protocols when discrepancies arise.

B. Take Vital Signs.

Incorrect Explanation: Taking vital signs might not directly address the concern about the head circumference measurement.

Explanation: Vital signs (like heart rate, respiratory rate, blood pressure) are important indicators of a patient's overall health, but they may not directly address the issue of the head circumference measurement discrepancy.

C. Report to the MD/NP/PA in charge of the patient the head circumference that you obtained as well as the patient's current status. Expect that they will also re-measure.

Correct Explanation: This is the best next step.

Explanation: When there's a discrepancy in a critical measurement like head circumference, it's important to communicate this to the responsible healthcare provider (MD/NP/PA). They need to be aware of any changes in the patient's condition and measurements, and they will likely want to re-measure or reassess the situation themselves to ensure accuracy.

D. Move your measuring tape to above the mid-forehead, so that your number matches the findings from the week before.

Incorrect Explanation: Fudging measurements to match previous data is not a professional or ethical approach.

Explanation: Altering measurements to match previous values, especially without proper indication, is not a responsible practice in healthcare. It's essential to ensure accurate and honest documentation.

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Correct Answer is A

Explanation

A. "I will continue to check his blood sugar two times every day."

Correct Explanation: This statement indicates a need for further instruction.

Explanation: A child with type 1 diabetes requires frequent blood sugar monitoring, especially during illness. Checking blood sugar only twice a day is not sufficient, especially when the child has an upper respiratory infection. Illness can impact blood sugar levels, so more frequent monitoring is necessary to ensure proper diabetes management.

B. "I will report a change in her breathing or any signs of confusion."

Incorrect Explanation: This statement shows awareness of potential complications and the need to monitor for them.

Explanation: Children with type 1 diabetes are at risk of diabetic ketoacidosis (DKA) when they are sick. Changes in breathing patterns and signs of confusion are symptoms of DKA. Reporting these symptoms is important, as it could indicate a serious diabetic complication.

C. "I will encourage her to drink half a cup of water or sugar-free fluid every 30 minutes."

Incorrect Explanation: This statement demonstrates proper fluid management, especially during illness.

Explanation: Encouraging the child to stay hydrated with sugar-free fluids is essential, particularly when the child has an upper respiratory infection. Proper hydration helps prevent dehydration, which can be more concerning for a child with diabetes.

D. "I will notify the doctor if her temperature is not controlled by acetaminophen."

Incorrect Explanation: This statement shows an understanding of the importance of managing fever in a child with diabetes.

Explanation: Children with diabetes can experience difficulty managing blood sugar levels when they're sick. Fever can exacerbate this issue. Using acetaminophen to control fever is appropriate, and notifying the doctor if fever persists is a responsible action.

A. You do not need to lose consciousness to suffer a concussion, B. You will suffer permanent brain damage C. We encourage fluids after a concussion D. Bleeding always occurs with a concussion

Correct Answer is A

Explanation

A. You do not need to lose consciousness to suffer a concussion.

This statement is true. Concussion is a type of traumatic brain injury (TBI) that can occur without loss of consciousness. Many concussions happen without the person losing consciousness at all.

B. You will suffer permanent brain damage.

This statement is not necessarily true. While some concussions can lead to lasting effects, not all cases result in permanent brain damage. The severity and long-term effects of a concussion can vary widely.

C. We encourage fluids after a concussion.

This statement is true. Adequate hydration is important after a concussion. Staying hydrated can help support the brain's recovery process.

D. Bleeding always occurs with a concussion.

This statement is not true. Concussion is defined by the disruption of normal brain function due to a blow or jolt to the head or body, and bleeding is not always a necessary component of a concussion. However, more severe head injuries could involve bleeding and would not be classified as just a concussion.

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When measuring a 6-month-old baby in the hospital for seizures, the nurse obtains a head circumference that is up 1 cm from the last measurement one week ago. The nurse re-measures and gets the same number What is the best next step?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 7-year-old child who has an upper respiratory infection and type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?

Correct Answer is A

Explanation

Evidence has demonstrated that we can do a great deaI to prevent and minimalize the occurence of CTE (Concussion Tramatic Encephalophy), damage due to repetitive head injuries. Which of the answers below are true:

Correct Answer is A

Explanation

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