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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Elevate the head of the bed 15 to 30 degrees with head maintained a midline position.

Correct Explanation: This intervention is appropriate for a child with an acute head injury.

Explanation: Elevating the head of the bed helps reduce intracranial pressure by facilitating venous drainage from the head. However, it's important to keep the head in a midline position to prevent neck flexion, which can obstruct venous flow. Elevating the head 15 to 30 degrees is a standard approach for managing intracranial pressure in patients with head injuries.

B. Maintain an active stimulating environment.

Incorrect Explanation: Maintaining an active stimulating environment is not suitable for a child with an acute head injury.

Explanation: A child with an acute head injury should be in a quiet and calm environment. Overstimulation can worsen the condition by increasing intracranial pressure. It's important to minimize stimuli to allow the brain to heal.

C. Perform active chest percussion and suctioning every 1 to 2 hours.

Incorrect Explanation: Chest percussion and suctioning are not relevant interventions for an acute head injury.

Explanation: Active chest percussion and suctioning are typically used to manage respiratory conditions. While maintaining good respiratory function is important for overall patient care, it's not a primary intervention for an unconscious child with a head injury.

D. Instruct child on performing active range of motion.

Incorrect Explanation: Instructing the child on performing active range of motion is not appropriate for an unconscious child with a head injury.

Explanation: An unconscious child cannot actively perform range of motion exercises. Additionally, it's not a priority intervention in the acute phase of head injury management.

A. "My son might complain of feeling shaky when he has a low blood glucose level B. "My son might have nausea and vomiting with hypoglycemia C. Sweating can occur with hyperglycemia D. The onset of low blood glucose usually occurs slowly

Correct Answer is A

Explanation

A. "My son might complain of feeling shaky when he has a low blood glucose level."

Explanation: Correct Choice. Shaking or feeling shaky is a common symptom of low blood glucose levels, also known as hypoglycemia. When blood sugar drops too low, the body releases adrenaline, causing shaking or trembling. This response is indicative of an understanding of hypoglycemia symptoms.

B. "My son might have nausea and vomiting with hypoglycemia."

Explanation: Nausea and vomiting are not typical symptoms of hypoglycemia (low blood sugar). They are more commonly associated with hyperglycemia (high blood sugar) or other conditions. This statement is not accurate in the context of hypoglycemia.

C. "Sweating can occur with hyperglycemia."

Explanation: Sweating is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia (high blood sugar). When blood sugar levels drop too low, the body can respond with sweating as part of the adrenaline release. Sweating is not a typical symptom of hyperglycemia.

D. "The onset of low blood glucose usually occurs slowly."

Explanation: The onset of low blood glucose (hypoglycemia) can vary. It can occur suddenly, especially if the individual takes too much insulin or diabetes medication, leading to a rapid drop in blood sugar. The correct understanding is that the onset of low blood glucose can be rapid and not always slow.

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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

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Explanation

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Explanation

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