Nokea
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
- A. Which assessment finding three hours after admission should be reported to the physician for a five-year-old with a closed head injury?
- B. The client has slight edema of the eyelids.
- C. There is clear fluid draining from the client’s right ear.
- D. There is some bleeding from the child’s lacerations.
- E. The client withdraws in response to painful stimuli.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.
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During the first 24 hours after total parenteral nutrition (TPN) therapy is started.
The nurse should
- A. monitor vital signs every two hours.
- B. determine urinalysis results.
- C. evaluate blood glucose levels.
- D. compare weight with the previous readings.
Correct Answer: C
Rationale: Strategy: Determine how each assessment relates to TPN. (1) inappropriate (2) inappropriate (3) correct-total parenteral nutrition (TPN), or hyperalimentation, has a high glucose content; important to monitor glucose levels (4) appropriate, but not a priority
The nurse assesses an 18-month-old child brought to the well child clinic for a routine check-up. Which finding would be of most concern to the nurse?
- A. The child can creep up stairs.
- B. The child is not toilet trained.
- C. The child drops objects handed to him.
- D. The child cries when his mother leaves him with a stranger.
Correct Answer: C
Rationale: Dropping objects handed to him suggests motor or neurological issues at 18 months, requiring evaluation. Creeping , not being toilet trained , and stranger anxiety are normal.
A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
- A. Reassure the client that there are no snakes
- B. Turn the lights on brighter
- C. Tell the client that while he may see snakes, there are really no snakes
- D. Reassure the client that the snakes will not hurt him
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.
The client who is receiving hydantoin (Dilantin) tells the nurse his urine is pink-colored. What action should the nurse take?
- A. Report this serious side effect immediately to the physician
- B. Reassure the client that this occurs often in persons taking Dilantin
- C. Ask the client if he drank cranberry juice or ate red gelatin recently
- D. Strain the client's urine for possible urinary tract stones
Correct Answer: C
Rationale: Pink urine may result from dietary factors like cranberry juice or red gelatin, which should be ruled out before assuming a Dilantin-related issue.
The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?
- A. Leave the graft site open to the air.
- B. Elevate the recipient site.
- C. Encourage range-of-motion exercises.
- D. Change the dressing twice a day.
Correct Answer: B
Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.