Nokea
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.
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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.
What finding is a clinical manifestation of increased intracranial pressure (ICP) in children?
- A. Low-pitched cry
- B. Sunken fontanel
- C. Diplopia, blurred vision
- D. Increased blood pressure
Correct Answer: C
Rationale: Diplopia and blurred vision are signs of increased ICP in children due to pressure on cranial nerves. High-pitched cry and bulging fontanel are typical, not low-pitched or sunken. Increased blood pressure is less common in children compared to adults.
The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. How should the nurse interpret this?
- A. Eye trauma
- B. Brain death
- C. Severe brainstem damage
- D. Neurosurgical emergency
Correct Answer: D
Rationale: A sudden fixed and dilated pupil in an unconscious child signals a neurosurgical emergency, often due to increased intracranial pressure or unilateral brain damage. Eye trauma is less likely, brain death involves bilateral fixed pupils, and pinpoint pupils suggest brainstem damage.
A 10-year-old boy on a bicycle has been hit by a car in front of a school. The school nurse immediately assesses airway, breathing, and circulation. What should be the next nursing action?
- A. Place the child on his side.
- B. Take the childs blood pressure.
- C. Stabilize the childs neck and spine.
- D. Check the childs scalp and back for bleeding.
Correct Answer: C
Rationale: After ensuring airway, breathing, and circulation, stabilizing the neck and spine prevents further trauma in a suspected head or spinal injury. Positioning, blood pressure checks, or bleeding assessments follow to avoid exacerbating potential spinal injuries.
What test is never performed on a child who is awake?
- A. Dolls head maneuver
- B. Oculovestibular response
- C. Assessment of pyramidal tract lesions
- D. Funduscopic examination for papilledema
Correct Answer: B
Rationale: The oculovestibular response (caloric test) uses painful ice water instillation, performed only in comatose children. Dolls head maneuver, pyramidal tract assessment, and funduscopic exams are non-painful and can be done on awake children.