The nurse should recommend medical attention if a child with a slight head injury experiences:
a. Sleepiness. c. Headache, even if slight.
b. Vomiting, even once. d. Confusion or abnormal behavior.
ANS: D
Medical attention should be sought if the child exhibits confusion or abnormal behavior; loses consciousness; or has amnesia, fluid leaking from the nose or ears, blurred vision, or unsteady gait. Sleepiness alone does not require evaluation. If the child is difficult to arouse from sleep, medical attention should be obtained. Vomiting more than three times requires medical attention. Severe or worsening headache or one that interferes with sleep should be evaluated.
You might also like to view...
A patient is admitted to the intensive care unit with status asthmaticus. The patient is administered high doses of nebulized albuterol (Proventil). What electrolyte imbalance should the nurse expect with this patient?
A) Hyperkalemia B) Hypermagnesemia C) Hypocalcemia D) Hypokalemia
Why is it important for the interdisciplinary team to assess an older patient's level of pain?
1. Validate that the pain is real. 2. Ensure pain management is provided. 3. Differentiate pain symptoms from other symptoms. 4. Provide the appropriate amount of help for normal activities.
The client who has been diagnosed with PAD has a nursing diagnosis of Risk for Impaired Skin Integrity related to decreased peripheral circulation. Which of the following interventions is most appropriate for this client?
1. Instruct client on protecting the legs from injury because tissue is fragile and any wound is likely to heal slowly. 2. Instruct client on appropriate level of activity to promote circulation. 3. Instruct client on risk factors that may increase problems with PAD. 4. Instruct client on PAD signs and symptoms.
Which intervention should be included in the plan of care for an infant with the nursing diagnosis Fluid volume excess related to congestive heart failure?
a. Weigh the infant every day on the same scale at the same time. b. Notify the physician when weight gain ex-ceeds more than 20 g/day. c. Put the infant in a car seat to minimize movement. d. Administer digoxin (Lanoxin) as ordered by the physician.