A child sustains a traumatic brain injury and is monitored in the pediatric intensive-care unit (PICU). The nurse is using the Glasgow Coma Scale to assess the child. Which items will the nurse assess when using this tool?
1. Eye opening
2. Verbal response
3. Motor response
4. Head circumference
5. Pulse oximetry
Correct Answer: 1,2,3
Rationale: The Glasgow Coma Scale for infants and children scores parameters related to eye opening, verbal response, and motor response. The maximum score is 15, indicating the highest level of neurological functioning. Head circumference and pulse oximetry are not included on the scale.
You might also like to view...
The breast-feeding mother should be taught a safe method to remove her breast from the baby's mouth. Which suggestion by the nurse is most appropriate?
a. Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed. b. Break the suction by inserting your finger into the corner of the infant's mouth. c. A popping sound occurs when the breast is correctly removed from the infant's mouth. d. Elicit the Moro reflex in the baby to wake the baby up, and remove the breast when the baby cries.
Priority nursing actions to achieve critical goals in the postoperative period for a client who has just returned from a Billroth II procedure should include
a. encouraging oral intake. b. ensuring frequent coughing and deep breathing. c. irrigating the client's NG tube every hour. d. maintaining the client in the semi-Fowler position.
Ordered: 15,000 units of heparin in 500 mL D5W infusing at 25 mL/h. The hourly heparin dose is ________.
Fill in the blank(s) with the appropriate word(s).
Vomiting is associated with central nervous system (CNS) injuries that compress which of the brain’s anatomic locations?
a. Vestibular nuclei in the lower brainstem b. Floor of the third ventricle c. Any area in the midbrain d. Diencephalon