Which is the most appropriate nursing action for a school-age child who has sustained a head injury and multiple fractures after being thrown from a horse and whose level of consciousness is variable?

Discuss with the family the child's previous history of injury.

Consult with the practitioner about what analgesia can be safely administered.

Explain that analgesia may mask signs of a decreasing level of consciousness.

Teach the family that adjunctives such as benzodiazepines are preferred for head injuries.

Answer and Explanation

The Correct Answer is B

Choice A reason: Discussing the child's previous history of injury is important, but it does not address the immediate concern of pain management.

Choice B reason: Consulting with a practitioner to determine safe analgesia options is crucial for managing pain while also monitoring the child's variable consciousness levels.

Choice C reason: While it is true that analgesia can mask neurological symptoms, it is essential to manage pain effectively, and the healthcare team can monitor for changes in consciousness.

Choice D reason: Teaching the family about specific medications like benzodiazepines is not the most immediate concern and should be left to the practitioner's discretion based on the child's condition. Pain management and safety are the priorities.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice. Thick pulmonary secretions are a hallmark of cystic fibrosis and must be addressed in the care plan.
Choice B reason: While cystic fibrosis can affect various glands, the primary concern is the respiratory system.
Choice C reason: Elevated levels of chloride, not potassium, are found in the sweat of individuals with cystic fibrosis.
Choice D reason: Cystic fibrosis is an autosomal recessive disorder, not dominant. This is important for genetic counseling and understanding the inheritance pattern.

A. Pulselessness. B. Ecchymotic area. C. Redness. D. Enlarged vein.

Correct Answer is D

Explanation

Choice A reason: Pulselessness is not a sign of normal AV fistula function; a palpable pulse should be present.
Choice B reason: An ecchymotic area suggests bruising and is not indicative of normal function.
Choice C reason: Redness may indicate inflammation or infection, not normal function.
Choice D reason: This is the correct choice. An enlarged vein is typical for an AV fistula and indicates good blood flow through the fistula.

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Which is the most appropriate nursing action for a school-age child who has sustained a head injury and multiple fractures after being thrown from a horse and whose level of consciousness is variable?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Betty is a 9-year-old girl diagnosed with cystic fibrosis. Which of the following must you, as the nurse, keep in mind when developing a care plan for the child?

Correct Answer is A

Explanation

The nurse is assessing a patient’s arteriovenous (AV) fistula. Which finding provides evidence of its normal function?

Correct Answer is D

Explanation

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