Nokea
A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse immediately assesses airway, breathing, and circulation. What should be the next nursing action?
- A. Place the child on his side.
- B. Take the childs blood pressure.
- C. Stabilize the childs neck and spine.
- D. Check the childs scalp and back for bleeding.
Correct Answer: C
Rationale: After ensuring airway, breathing, and circulation, stabilizing the neck and spine prevents further trauma in a suspected head or spinal injury. Positioning, blood pressure checks, or bleeding assessments follow to avoid exacerbating potential spinal injuries.
You may also like to solve these questions
What statement best describes a subdural hematoma?
- A. Bleeding occurs between the dura and the skull.
- B. Bleeding occurs between the dura and the cerebrum.
- C. Bleeding is generally arterial, and brain compression occurs rapidly.
- D. The hematoma commonly occurs in the parietotemporal region.
Correct Answer: B
Rationale: Subdural hematoma involves bleeding between the dura and cerebrum from ruptured cortical veins. Bleeding between dura and skull is epidural, arterial bleeding with rapid compression is typical of epidural hematomas, and parietotemporal location is more common in epidural cases.
What nursing intervention is appropriate when caring for an unconscious child?
- A. Avoid using narcotics or sedatives to provide comfort and pain relief.
- B. Change the childs position infrequently to minimize the chance of increased intracranial pressure (ICP).
- C. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
- D. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are contraindicated.
Correct Answer: C
Rationale: Monitoring fluid intake and output prevents overhydration, which can cause cerebral edema in unconscious children. Narcotics and sedatives are used for comfort, frequent repositioning prevents complications, and antipyretics are preferred over sponge baths for fever.
What term is used when a patient remains in a deep sleep, responsive only to vigorous and repeated stimulation?
- A. Coma
- B. Stupor
- C. Obtundation
- D. Persistent vegetative state
Correct Answer: B
Rationale: Stupor describes a deep sleep state requiring vigorous, repeated stimulation to respond. Coma involves no response to painful stimuli, obtundation allows arousal with less stimulation, and persistent vegetative state indicates permanent cerebral cortex loss.
An injury to which part of the brain will cause a coma?
- A. Brainstem
- B. Cerebrum
- C. Cerebellum
- D. Occipital lobe
Correct Answer: A
Rationale: Brainstem injury disrupts consciousness, leading to stupor or coma. Cerebral injuries cause specific deficits like memory loss, cerebellar injuries impair coordination, and occipital lobe injuries affect vision, none of which directly cause coma.
The nurse is preparing a school-age child for computed tomography (CT) scan to assess cerebral function. The nurse should include what statement in preparing the child?
- A. The scan will not hurt.
- B. Pain medication will be given.
- C. You will be able to move once the equipment is in place.
- D. Unfortunately no one can remain in the room with you during the test.
Correct Answer: A
Rationale: CT scans are painless, requiring immobilization, and this should be emphasized to reduce anxiety. Pain medication isn?t needed, movement is restricted during the scan, and a caregiver can often stay with the child, depending on facility protocols.