Nokea
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.
You may also like to solve these questions
An adolescent has just had a generalized seizure and collapsed in the school nurse's office. When should the nurse should call 911?
- A. The seizure lasts more than 5 minutes.
- B. The child is sleepy and lethargic after the seizure.
- C. The child vomited at the onset of the seizure.
- D. The child is confused and has slurred speech after the seizure.
Correct Answer: A
Rationale: If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.
Which assessment finding in a child with meningitis should be reported immediately?
- A. Irregular respirations
- B. Tachycardia
- C. Slight drop in blood pressure
- D. Elevated temperature
Correct Answer: A
Rationale: Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately, because they could indicate increased intracranial pressure.
A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect?
- A. Meningitis
- B. Reye's syndrome
- C. Brain tumor
- D. Encephalitis
Correct Answer: C
Rationale: The signs and symptoms of a brain tumor are related to its size and location, creating increased intracranial pressure with hallmark symptoms of headache, vomiting, drowsiness, and seizures.
What symptom leads the nurse caring for a 5-month-old child with viral influenza to suspect the development of Reye's syndrome?
- A. Respirations drop from 18 to 14 breaths/minute
- B. Falling asleep after feeding
- C. Sudden vomiting without effort
- D. Development of a macular rash
Correct Answer: C
Rationale: A child with a viral infection is at risk for Reye's syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness.
The nurse observes a child's position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture?
- A. Correct anatomical position
- B. Decorticate
- C. Decerebrate
- D. Opisthotonos
Correct Answer: C
Rationale: In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.