The nurse working in an urgent care center admits a 5-year-old who fell while riding her bicycle. The child is awake but sleepy, which could be explained by it being close to bedtime
The nurse assesses pupil response and finds the left eye responds rapidly and constricts to 2 mm, while the right eye responds more slowly and constricts to 5 mm. The nurse will: 1. Prepare to transfer the child to the hospital.
2. Instruct the parents to wake the child every two hours and assess mentation.
3. Administer ordered narcotic analgesic for pain.
4. Encourage the child to cough and deep-breathe.
1
Rationale: Uneven pupillary response is indicative of neurological trauma, and the child will need to be admitted to the hospital for further testing and observation. Narcotic analgesics will reduce the ability to obtain an accurate neurological assessment, so they are contraindicated. Coughing and deep-breathing can increase intracranial pressure, and would be contraindicated in a child with an uneven pupillary response who might have elevated ICP.
You might also like to view...
When integrating the principles of family-centered maternity care, the nurse would include which of the following?
A) View of childbirth as a procedure B) Families unable to make informed choices C) Childbirth results in changes in relationships D) Families are inflexible in decision making
A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already.". The best response for the nurse to make would be:
a. "I wonder what this sudden change is all about. Care to elaborate?" b. "I am glad you are feeling better. The team will consider what you have said.". c. "You should not try to direct your plan for care. Leave that to the team.". d. "Because we are concerned about your safety, we will continue with our plan.".
The nurse is caring for a patient with chronic pancreatitis and a serum amylase level of 180 units/L. Which dietary plan should the nurse instruct the patient to follow?
1. low residue, no alcohol 2. low fat, no alcohol 3. low fat, no fiber 4. mechanical soft
A patient is planning to perform incentive spirometry after abdominal surgery. The nurse should encourage the patient to do which of the following?
a. Get comfortable in a semi-reclined position. b. Inhale as deeply as possible and then exhale into the incentive spirometry device. c. Hold the breath for at least 3 seconds before exhaling. d. Exhale as quickly as possible.