Nokea
Which of the following statements is true regarding Glasgow coma scale (GCS) in children?
- A. The scale is validated as a prognostic scoring system in children and young infants
- B. Patients with GCS < or = 8 require aggressive management
- C. All patients with GCS < or = 5 should be intubated and mechanically ventilated
- D. It is useful in children to assess the neurological, circulatory and cardiac status
Correct Answer: B
Rationale: Patients with a GCS of 8 or less require aggressive management, as this indicates severe brain injury and potential airway compromise.
You may also like to solve these questions
The parents of a 3-month-old ask why their baby will not have an operation to correct a ventricular septal defect (VSD). The nurse's best response is:
- A. It is always helpful to get a second opinion about any serious condition like this.
- B. Your baby's defect is small and will likely close on its own by 1 year of age.
- C. It is common for physicians to wait until an infant develops respiratory distress before they do the surgery.
- D. With a small defect like this, they wait until the child is 10 years old to do the surgery.
Correct Answer: B
Rationale: Most small VSDs close spontaneously within the first year of life.
The nurse is caring for a child with a diagnosis of Kawasaki disease. The child's parent asks the nurse, 'How does Kawasaki disease affect my child's heart and blood vessels?' On what understanding is the nurse's response based?
- A. Inflammation weakens blood vessels, leading to aneurysm.
- B. Increased lipid levels lead to the development of atherosclerosis.
- C. Untreated disease causes mitral valve stenosis.
- D. Altered blood flow increases cardiac workload with resulting heart failure.
Correct Answer: A
Rationale: Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.
In urgent situations of supraventricular tachycardia (SVT) when symptoms of severe heart failure have already occurred, the initial management is
- A. adenosine by rapid intravenous push
- B. DC cardioversion
- C. verapamil
- D. digoxin
Correct Answer: B
Rationale: DC cardioversion is the preferred initial management in hemodynamically unstable SVT.
Which clinical manifestation is included in toxic shock syndrome?
- A. Severe hypertension
- B. Subnormal temperature
- C. Erythematous macular rash
- D. Papular rash over extremities
Correct Answer: C
Rationale: One of the diagnostic criteria for toxic shock syndrome is a diffuse macular erythroderma. Hypotension is one of the manifestations. Fever of 38.9° C or higher is a characteristic. Desquamation of the palms and soles of the feet occurs in about 1 to 2 weeks.
Which should the nurse consider when preparing a school-age child and the family for heart surgery?
- A. Unfamiliar equipment should not be shown.
- B. Let the child hear the sounds of an ECG monitor.
- C. Avoid mentioning postoperative discomfort and interventions.
- D. Explain that an endotracheal tube will not be needed if the surgery goes well.
Correct Answer: B
Rationale: The child and family should be exposed to the sights and sounds of the intensive care unit (ICU). All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous (IV) lines, incision, and endotracheal tube.