11. An appropriate nursing intervention when caring for an unconscious : 1361546

11. An appropriate nursing intervention when caring for an unconscious : 1361546.


11. An appropriate nursing intervention when caring for an unconscious child should be to:

a. change the child’s position infrequently to minimize the chance of increased ICP.

b. avoid using narcotics or sedatives to provide comfort and pain relief.

c. monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.

d. give tepid sponge baths to reduce fever because antipyretics are contraindicated.

12. The nurse is planning care for an 8-year-old child with a concussion. Which is descriptive of a concussion?

a. Petechial hemorrhages cause amnesia.

b. Visible bruising and tearing of cerebral tissue occur.

c. It is a transient and reversible neuronal dysfunction.

d. A slight lesion develops remotely from the site of trauma.

13. The nurse is teaching nursing students about childhood fractures. Which describes a compound skull fracture?

a. Involves the basilar portion of the occipital bone

b. Bone is exposed through the skin

c. Traumatic separations of the cranial sutures

d. Bone is pushed inward, causing pressure on the brain

14. Which 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.

15. The nurse should recommend medical attention if a child with a slight head injury experiences:

a. sleepiness.

b. vomiting, even once.

c. headache, even if slight.

d. confusion or abnormal behavior.

16. A 10-year-old boy on a bicycle has been hit by a car in front of the school. The school nurse immediately assesses airway, breathing, and circulation. The next nursing action: should be to

a. place on side.

b. take blood pressure.

c. stabilize neck and spine.

d. check scalp and back for bleeding.

17. An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. The nurse should suspect which type of head injury?

a. Brainstem

b. Skull fracture

c. Subdural hemorrhage

d. Epidural hemorrhage

18. A child is unconscious after a motor vehicle accident. The watery discharge from the nose tests positive for glucose. The nurse should recognize that this suggests:

a. diabetic coma.

b. brainstem injury.

c. upper respiratory tract infection.

d. leaking of cerebrospinal fluid (CSF).

19. A toddler fell out of a second-story window. She had a brief loss of consciousness and vomited four times. Since admission, she has been alert and oriented. Her mother asks why a computed tomography (CT) scan is required when she “seems fine.” Which explanation should the nurse give?

a. Your child may have a brain injury and the CT can rule one out.

b. The CT needs to be done because of your child’s age.

c. Your child may start to have seizures and a baseline CT should be done.

d. Your child probably has a skull fracture and the CT can confirm this diagnosis.

20. The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. Which is the most essential part of the nursing assessment to detect early signs of a worsening condition?

a. Posturing

b. Vital signs

c. Focal neurologic signs

d. Level of consciousness



11. An appropriate nursing intervention when caring for an unconscious : 1361546

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