Nokea
A 12-year-old child has had a traumatic head injury from playing in a football game. He is admitted to the emergency department and transferred to the pediatric intensive care unit. He has an I.V. of dextrose 5% in water at a 'keep-open' rate and nasal oxygen at 2 L/minute. The nurse is assessing the child at the beginning of the shift (11:00 p.m.) and reviews the Glasgow Coma Scale flow sheet. The nurse notes that the child responds to pain, is making incomprehensible sounds, and has abnormal flexion of the limbs. What should the nurse do first?
- A. Notify the physician.
- B. Administer pain medication.
- C. Increase oxygen flow.
- D. Document the findings.
Correct Answer: A
Rationale: A Glasgow Coma Scale score indicating pain response, incomprehensible sounds, and abnormal flexion (approximately 6-8) suggests severe neurological impairment, warranting immediate physician notification.
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Immediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child?
- A. On the back with the head in a position of comfort.
- B. In low Fowler's position with the head turned to the side.
- C. Lying on the abdomen with the head turned to the side.
- D. In reverse Trendelenburg with the head tilted forward.
Correct Answer: C
Rationale: Lying on the abdomen with the head turned to the side facilitates drainage and reduces the risk of aspiration post-surgery.
The parents of a neonate born with congenital clubfoot express feelings of helplessness and guilt, exhibiting anxiety about how the neonate will be treated. Which of the following actions by the nurse would be most appropriate initially?
- A. Ask them to share these concerns with the physician.
- B. Arrange a meeting with other parents whose infants have clubfoot to discuss their feelings.
- C. Suggest that they make an appointment to talk things over with a counselor.
- D. Encourage the parents to express their feelings and listen attentively.
Correct Answer: D
Rationale: Encouraging expression of feelings and listening attentively is the most appropriate initial step to address emotional concerns and build trust.
The parents of a neonate with hypospadias and chordee wish to have him circumcised. Which of the following explanations should the nurse incorporate into the discussion with the parents concerning the recommendation to delay circumcision?
- A. The associated chordee is difficult to remove during circumcision.
- B. The foreskin is used to repair the deformity surgically.
- C. The meatus can become stenosed, leading to urinary obstruction.
- D. The infant is too small to have a circumcision.
Correct Answer: B
Rationale: The foreskin is needed for surgical repair.
Which statements by the mother of a toddler should lead the nurse to suspect that the child is at risk for iron deficiency anemia?
- A. He drinks over three cups of milk per day.
- B. I can't keep enough apple juice in the house; he must drink over 10 oz per day.
- C. He refuses to eat more than two different kinds of vegetables.
- D. He doesn't like meat; I don't think that he will eat small amounts of it.
- E. He sleeps 12 hours every night and takes a 2-hour nap.
Correct Answer: A,C,D
Rationale: Excess milk, limited vegetables, and low meat intake reduce iron intake, increasing anemia risk. Apple juice and sleep patterns are unrelated.
When performing cardiopulmonary resuscitation (CPR), which of the following indicates that external chest compressions are effective?
- A. Mottling of the skin.
- B. Pupillary dilation.
- C. Palpable pulse.
- D. Cool, dry skin.
Correct Answer: C
Rationale: A palpable pulse during CPR indicates effective chest compressions, as it confirms adequate circulation.