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A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?
- A. Hematemesis and abdominal distention.
- B. Asymmetry of the face and eye movements.
- C. Rhinorrhoea or otorrhoea with Halo sign.
- D. Abnormal position and movement of the arm.
Correct Answer: C
Rationale: The correct answer is C: Rhinorrhoea or otorrhoea with Halo sign. This finding is consistent with a basilar skull fracture because it indicates a cerebrospinal fluid (CSF) leak from the skull base. The Halo sign refers to a ring of CSF surrounded by blood, which can be seen on a white absorbent pad. This specific sign is a classic indicator of a basilar skull fracture, as the CSF leakage from the ears or nose can be tinged with blood due to the fracture disrupting nearby blood vessels.
For the other choices:
A: Hematemesis and abdominal distention are not typical manifestations of a basilar skull fracture. They are more indicative of gastrointestinal issues or internal bleeding.
B: Asymmetry of the face and eye movements can be seen with facial nerve or orbital injuries, but it is not specific to a basilar skull fracture.
D: Abnormal position and movement of the arm are not directly related to a
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What nursing strategies help families cope with the stress of critical illness? (Select all that apply.)
- A. Asking the family to leave during the morning bath to promote the patient’s privacy.
- B. Encouraging family members to make notes of questio ns they have for the physician during family rounds.
- C. When possible, providing continuity of nursing care.
- D. Providing a daily update of the patient’s condition to the family spokesperson.
Correct Answer: B
Rationale: The correct answer is B: Encouraging family members to make notes of questions they have for the physician during family rounds. This strategy helps families cope with the stress of critical illness by empowering them to stay informed and actively participate in the patient's care. By encouraging them to make notes, it promotes effective communication with the healthcare team and ensures that their concerns and questions are addressed promptly.
Other choices are incorrect:
A: Asking the family to leave during the morning bath to promote the patient’s privacy is not a helpful strategy for coping with stress as it may lead to feelings of isolation and lack of involvement in the patient's care.
C: Providing continuity of nursing care is important but may not directly address the family's coping mechanisms during a critical illness.
D: Providing a daily update of the patient’s condition to the family spokesperson is valuable but may not fully address the family's need for active participation and communication with the healthcare team.
A 45-year-old postsurgical patient is on a ventilator in the critical care unit has been tolerating the ventilator well and has not required any sedation. The apbairtbi.ecnomt /bteesct omes tachycardic and hypertensive with a respiratory rate that has increased to 28 breaths/min. The ventilator is set on synchronized intermittent mandatory ventilation (SIMV ) at a rate of 10 breaths/min. The patient has been suctioned recently via existing endotracheal tube until airway is clear. When the patient responds appropriately to the nurse’s command s, what should be the nurse’s priority intervention?
- A. Assessing the patient’s level of pain
- B. Decreasing the SIMV rate on the ventilator
- C. Providing sedation as ordered
- D. Suctioning the patient again
Correct Answer: A
Rationale: The correct answer is A: Assessing the patient's level of pain. In this situation, the patient's tachycardia, hypertension, and increased respiratory rate could be indicative of pain. By assessing the patient's pain level, the nurse can address any discomfort the patient may be experiencing, which could be contributing to these physiological responses.
Summary of other choices:
B: Decreasing the SIMV rate on the ventilator - This is not the priority intervention as the patient's symptoms are more likely related to pain rather than the ventilator settings.
C: Providing sedation as ordered - Sedation is not the priority in this case as the patient has been tolerating the ventilator well without requiring sedation.
D: Suctioning the patient again - Since the airway has been recently cleared, suctioning again is not necessary at this point and would not address the underlying cause of the patient's symptoms.
The critical care environment is stressful to the patient. Which interventions assist in reducing this stress? (Select all that apply.)
- A. Adjust lighting to promote normal sleep-wake cycles.
- B. Provide clocks, calendars, and personal photos in the p atient’s room.
- C. Talk to the patient about other patients you are caring for on the unit.
- D. Tell the patient the day and time when you are providi ng routine nursing interventions.
Correct Answer: A
Rationale: Correct Answer: A. Adjust lighting to promote normal sleep-wake cycles.
Rationale:
1. Adjusting lighting can help regulate the patient's circadian rhythm, promoting better sleep and reducing stress.
2. Normal sleep-wake cycles are crucial for overall well-being and healing in a critical care setting.
3. Proper lighting can also create a more calming environment for the patient.
Summary of Incorrect Choices:
B. Providing clocks, calendars, and personal photos can be overwhelming for a stressed patient.
C. Talking about other patients may increase anxiety and breach patient confidentiality.
D. Telling the day and time of routine interventions may disrupt the patient's sense of time and add to stress.
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
- A. Obtain the permission of the custodial parent for the surgery.
- B. Notify the non-custodial parent to also sign a consent form.
- C. Instruct the client sign the consent before giving medications.
- D. Obtain the signature of the client’s stepfather for the surgery.
Correct Answer: A
Rationale: The correct answer is A: Obtain the permission of the custodial parent for the surgery. In this scenario, the client is a minor (16 years old), which means they are not legally able to provide informed consent for medical procedures. The custodial parent holds legal responsibility for the minor's healthcare decisions. Thus, obtaining the permission of the custodial parent is crucial to ensure valid informed consent.
Choice B is incorrect because the non-custodial parent's consent may not be legally required if the custodial parent is available to provide consent. Choice C is incorrect because obtaining consent should precede any administration of medications. Choice D is incorrect as the stepfather's consent may not hold legal weight unless designated as a legal guardian.
The patient is in the critical care unit and will receive dialysis this morning. The nurse will (Select all that apply.)
- A. evaluate morning laboratory results and report abnormal results.
- B. administer the patient’s antihypertensive medications.
- C. assess the dialysis access site and report abnormalities.
- D. weigh the patient to monitor fluid status.
Correct Answer: A
Rationale: The correct answer is A because evaluating morning lab results is crucial to monitor the patient's condition before dialysis. Abnormal results may impact the dialysis treatment plan. Option B is incorrect as administering antihypertensive medications is not directly related to dialysis. Option C is incorrect as assessing the dialysis access site is the responsibility of the dialysis team. Option D is incorrect as weighing the patient is not typically done immediately before dialysis.