Nokea
A school-age child has sustained a head injury and multiple fractures after being thrown from a horse. The childs level of consciousness is variable. The parents tell the nurse that they think their child is in pain because of periodic crying and restlessness. What is the most appropriate nursing action?
- A. Explain that analgesia is contraindicated with a head injury.
- B. Have the parents describe the childs previous experiences with pain.
- C. Consult with a practitioner about what analgesia can be safely administered.
- D. Teach the parents that analgesia is unnecessary when the child is not fully awake and alert.
Correct Answer: C
Rationale: Consulting a practitioner ensures safe analgesia administration to manage pain and reduce ICP from anxiety, while monitoring neurologic status. Analgesia is not contraindicated, past pain history is secondary, and pain relief is necessary despite reduced consciousness.
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What is a nursing intervention to reduce the risk of increasing intracranial pressure (ICP) in an unconscious child?
- A. Suction the child frequently.
- B. Turn the childs head side to side every hour.
- C. Provide environmental stimulation.
- D. Avoid activities that cause pain or crying.
Correct Answer: D
Rationale: Avoiding pain or crying prevents ICP increases, as these raise intracranial pressure. Frequent suctioning, head turning, and environmental stimulation can elevate ICP and are contraindicated or require careful management, such as pre-suction hyperventilation.
The mother of a 1-month-old infant tells the nurse she worries that her baby will get meningitis like the childs younger brother had when he was an infant. The nurse should base a response on which information?
- A. Meningitis rarely occurs during infancy.
- B. Often a genetic predisposition to meningitis is found.
- C. Vaccination to prevent all types of meningitis is now available.
- D. Vaccinations to prevent pneumococcal and Haemophilus influenzae type B meningitis are available.
Correct Answer: D
Rationale: Vaccines for pneumococcal and H. influenzae type B meningitis have reduced their incidence, but group B streptococci and E. coli are common neonatal causes. Meningitis is serious in infancy, no genetic predisposition is noted, and vaccines don?t cover all causes.
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.
An 18-month-old child is brought to the emergency department after being found unconscious in the family pool. What does the nurse identify as the primary problem in drowning incidents?
- A. Hypoxia
- B. Aspiration
- C. Hypothermia
- D. Electrolyte imbalance
Correct Answer: A
Rationale: Hypoxia is the primary problem in drowning, causing rapid global cell damage, especially to neurons, within 4-6 minutes. Aspiration leads to pulmonary complications, hypothermia occurs but is secondary, and electrolyte imbalances are not the primary cause of morbidity.
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.