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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This statement is not accurate and may cause unnecessary distress, as Guillain-Barré Syndrome often does not result in a lifelong prognosis.
Choice B reason: This statement is overly optimistic and may not be accurate, as recovery times can vary greatly between individuals.
Choice C reason: This response provides a realistic expectation without causing undue alarm, acknowledging the temporary nature of the paralysis and the potential duration of recovery.
Choice D reason: While sensory loss can occur, it is not guaranteed, and the focus should be on the respiratory paralysis and the recovery process.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. If an orogastric tube fails to pass, it may indicate a blockage or abnormal connection, such as a tracheoesophageal fistula.
Choice B reason: Low birth weight can be associated with many conditions and is not specific to TEF.
Choice C reason: TEF is not typically visible without special imaging or procedures; it cannot be visually identified at delivery.
Choice D reason: Dry mouth and nares with little to no oral secretions could indicate other conditions and are not specific to TEF. TEF often presents with excessive oral secretions.
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