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A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion?
- A. Sleepy but easily arousable
- B. Complaining of a stiff neck
- C. Cannot remember what happened to him
- D. Pupils react sluggishly to light
Correct Answer: C
Rationale: A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness, often accompanied by a loss of memory of the events.
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What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
- A. Assist the child to bed and then go for help.
- B. Move objects out of the child's immediate area.
- C. Stick a padded tongue blade between the child's teeth.
- D. Manually restrain the child.
Correct Answer: B
Rationale: During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.
What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?
- A. Use gestures and signs as much as possible.
- B. Let the child's parents communicate for her.
- C. Face the child and speak clearly in short sentences.
- D. Recognize that the child's ability to communicate will be on a 6-year-old child's level.
Correct Answer: C
Rationale: The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.
An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented? (Select all that apply.)
- A. Parental education regarding prevention
- B. Respiratory support
- C. Cardiovascular support
- D. Controlled rewarming
- E. Adequate cerebral oxygenation
Correct Answer: B,C,D,E
Rationale: Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care.
The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.)
- A. Encourage books with large type.
- B. Words in books should be closely spaced.
- C. Provide adequate lighting without glare.
- D. Be sure desks and chairs are adequate height.
- E. Instruct child to squint when reading.
Correct Answer: A,C,D
Rationale: Children who are beginning to read need books with large type in which the letters are spaced far apart.
A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media?
- A. Infants are in a supine or prone position most of the time.
- B. Sucking on a nipple creates middle ear pressure.
- C. They have increased susceptibility to upper respiratory tract infections.
- D. The Eustachian tube is short, straight, and wide.
Correct Answer: D
Rationale: An infant's Eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear.