Nokea
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.
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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.
What term is used to describe a childs level of consciousness when the child is arousable with stimulation?
- A. Stupor
- B. Confusion
- C. Obtundation
- D. Disorientation
Correct Answer: C
Rationale: Obtundation describes a child arousable with stimulation but with reduced alertness. Stupor requires vigorous stimulation, confusion involves impaired decision-making, and disorientation pertains to time and place confusion.
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.
An injury to which part of the brain will cause a coma?
- A. Brainstem
- B. Cerebrum
- C. Cerebellum
- D. Occipital lobe
Correct Answer: A
Rationale: Brainstem injury disrupts consciousness, leading to stupor or coma. Cerebral injuries cause specific deficits like memory loss, cerebellar injuries impair coordination, and occipital lobe injuries affect vision, none of which directly cause coma.
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.