Test 3: Ch 52 Unintentional Injuries PrepU
A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. What is the priority intervention?
Administer 100% oxygen by mask.
A 7-year-old boy is brought to the emergency room by his parents following an accident in which he was struck in the back of the head with a baseball bat. The nurse is assessing him. What vital signs would indicate increased intracranial pressure in this child?
Decrease in pulse and respiratory rate and increase in temperature and pulse pressure
The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern?
Inspection shows a sluggish pupillary reaction. A sluggish pupillary reaction may occur with increased intracranial pressure, which would be cause for concern.
The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately?
Minimal air movement through the lungs
The nurse is providing community education regarding accidents in the infant, toddler and preschool population. When designing educationalmaterials, which types of accidents would be included?
Motor vehicles Falls Burns Water immersions
What is the antidote for acetaminophen toxicity?
Mucomyst
Which nursing diagnosis would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub?
Risk for suffocation
A child is brought to the emergency department after sustaining blunt trauma to his chest. What would lead the nurse to suspect that the child has a tension pneumothorax?
Tracheal deviation With a tension pneumothorax, a tear in the lung lining results in air accumulation in the pleural space compressing the lung. Typically the child exhibits unstable vital signs, respiratory distress, tracheal deviation, decreased breath sounds over the affected lung, cyanosis, and decreased cardiac output.
The nurse is caring for a child who has suffered a first-degree partial thickness burn to their forearm. What education should the nurse provide to the parents?
When a minor burn occurs, apply cool water, not ice, to the burn to cool the skin. Infection is a concern so application of an antibiotic ointment and a gauze dressing is indicated. A follow up appointment in about 2 days is indicated to change the dressing and assess for any infection. The dressing should be kept dry, no swimming or getting wet while bathing, until the burn is healed.
The student nurse is preparing a presentation on dental trauma care in children. What information should the student include?
When a permanent tooth is knocked out, it should be rinsed in water and then placed in a salt solution or milk and brought to the emergency department.
A 5-year-old child is exhibiting manifestations of hypotension. What is the first-line treatment for poor perfusion and hypotension?
Volume replacement
A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. What treatment is most likely appropriate in the immediate treatment of the girl's poisoning?
Administration of activated charcoal Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.
A child has fallen off of a swing at the playground and her father states that she became groggy. After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next?
Assess level of consciousness.
A 10-year-old boy with congenital heart disease is in shock. What nursing intervention would be most appropriate for this child?
Assessing for pulmonary edema from fluid overload
The nurse is caring for a 5-year-old child with a temperature of 102 °F (39 °C). The nurse is aware that fever in a 5-year-old child is most commonly associated with what?
Increased caloric needs Fever increases metabolic rate requiring a higher calorie intake. For each degree Celsius, caloric requirements increase by 12%. Febrile seizures occur most commonly in children between 6 months and 5 years of age. However, it is the fever that triggers the seizure, not the seizure triggering the fever.
Cardiopulmonary resuscitation (CPR) is in progress on an 8-year-old boy who is in shock. Which nursing intervention is priority?
Inserting an intraosseous needle via the femoral route
A nurse is providing instructions to the mother of a toddler regarding the prevention of burn injuries. Which instruction is of the highest priority?
Keep coffee cups on the counter above the child's reach.
A nurse is educating a mother about caring for a newborn baby. What should the nurse teach the client as a precautionary measure to protect the infant from burns?
Keep hot substances away from the baby.
The nurse is assessing the neurologic status of an infant. What would the nurse identify as a nonreassuring finding?
Lack of interest in surroundings
A child with a severe head injury arrives at the emergency department very groggy. She is subsequently difficult to arouse for several hours. The nurse would document this condition as what?
Stupor
The nurse is assessing a child who has been injured. What assessment finding would support the need to initiate a notification to the abuse registry so that child protection specialists can investigate?
The child and parent have conflicting stories on what caused the injury.
A 3-year-old child who is breathing very rapidly and shallowly has an oxygen saturation level of 90%. The child is also very apprehensive. What would be most appropriate?
Administer oxygen via a mask made out of a paper cup. For any child showing respiratory distress or desaturation on pulse oximetry, administer oxygen to keep saturation above 95% using a method tolerated by the child; in the instance of a child with extreme apprehension, the nurse can fashion a nonthreatening oxygen mask made with a styrofoam or paper cup and an oxygen cannula
A 14-month-old trauma victim has arrived in the emergency department. What client priority will the nurse need to address first?
Possible tissue damage from hypoxia oxygen should be administered by a non-rebreather mask until oxygenation and perfusion status is completely assessed. This will stabilize the effects of hypoxia
The effect of the bite of a rattlesnake, copperhead, or cottonmouth moccasin (all pit vipers) is the almost immediate failure of the blood coagulation system.
True
A 14-year-old girl arrives at the hospital in a comatose state. Her father, who found her comatose in her room, tells you that she has an opiate addiction. What pupil assessment would confirm that the coma was caused by opiate intoxication?
Both pupils are pinpoints Observe the child's eyes for signs of dilated pupils from increased ICP. If both pupils are dilated, irreversible brainstem damage is suggested, although such a finding may also be present with poisoning with an atropine-like drug. Pinpoint pupils suggest barbiturate or opiate intoxication. One pupil dilated or the eye deviated downward or laterally more than the other suggests third cranial nerve compression or a tentorial tear (laceration of the membrane between the cerebellum and cerebrum) with herniation of the temporal lobe into the torn membrane.
A child with a severe head injury arrives in the emergency department. Parents inform the nurse that after the injury, they have not been able to rouse the child. This nurse provides a report to the healthcare provider and suggest that the client may be experiencing what?
A coma
The child's palm represents approximately which percentage of the TBSA?
1% A quick assessment technique is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA.
The nurse is assessing a child with a suspected head injury. The child opens the eyes only in response to the nurse placing pressure in the child's nail bed. What score on the Glasgow coma scale for eye opening should the nurse assign based on this assessment finding?
2 In the eye opening section of the Glasgow coma scale, eye opening only in response to painful stimuli would be a score of 2. Spontaneous eye opening is a 4, opening in response to speech is a 3, and no eye opening in response to painful stimuli is a 1.
A child who weighs 53 lbs (24 kg) is receiving fluid volume replacement as part of the treatment for shock. The nurse is evaluating the child's hourly urinary output to determine if the child's condition is improving. Which output would the nurse interpret as most indicative of improvement?
24-48mL/hour Improved urinary output of 1 to 2 mL/kg/hour is the goal. The child weighs 53 pounds, which is equivalent to 24 kg. Thus, improvement in this child would be noted by an hourly urinary output between 24 and 48 mL/hour.
The nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnoses?
Acute pain
An infant arrives at the emergency department with vomiting, seizures, and irritability for the last 8 hours. A radiograph confirms bleeding into the space between the dura and arachnoid membrane. What diagnosis would the nurse expect the physician to make for this patient?
Subdural hematoma Subdural hematoma is venous bleeding into the space between the dura and arachnoid membrane. Signs and symptoms include seizures, increased intracranial pressure, vomiting, hyperirritability, and enlargement of the head.
A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which action should the nurse take first?
Establish a suitable IV site. The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs
What is the most frequently injured solid organ in a penetrating trauma?
Liver
The nurse is preparing the plan of care for a child experiencing respiratory distress. What action would be the top priority?
Maintaining a patent airway
A 13-year-old girl suffered a serious fall while hiking with friends and injured her head. She is now being evaluated by a nurse in the emergency room. The nurse notices clear fluid flowing from the girl's nose. The girl's friend said that she had been suffering from pollen allergy recently. Which of the following interventions should the nurse implement to determine whether the fluid is cerebrospinal fluid (CSF) or rhinitis from an allergy?
Test the fluid with a glucose reagent strip CSF will test positive for glucose, whereas the clear, watery drainage from an upper respiratory tract infection or allergy will not.
A nurse has rushed to the site of an accident where members of a family have suffered carbon monoxide poisoning. What is the highest priority action that must take place during carbon monoxide poisoning?
Remove the individual from the room. The first step in handling accidental carbon monoxide poisoning is to remove the individual from the site. If moving the person out of doors is impossible, rescuers should open windows and doors to reduce the level of toxic gas and promote the client's ventilation of air. Once emergency personnel arrive, they administer oxygen. CPR may or may not be necessary. In the case of extremely high blood levels of carbon monoxide, the victim may be treated with hyperbaric oxygen at a hospital.
The nurse is caring for a comatose school-age child receiving gastrostomy tube feedings. The nurse aspirates 15 ml of stomach contents prior to administering a feeding. What is the most appropriate action by the nurse?
Replace the stomach contents and continue with the feedings as prescribed. The nurse should always aspirate NG or gastrostomy tubes for stomach contents to check for tube placement and assess gastric residual amounts prior to administering feedings. Always return any amount of stomach reside aspirated so the child does not loose large amounts of stomach acid.
The nurse is providing care to a child experiencing shock. Which intravenous solution would the nurse expect to administer?
Ringer lactate Isotonic fluids, such as Ringer lactate or normal saline, are the fluids of choice given rapidly to children experiencing shock. Dextrose solutions are contraindicated in shock because of the risk of complications such as osmotic diuresis, hypokalemia, hyperglycemia, and worsening of ischemic brain injury
A 10 year old comes to the emergency department as a victim of child abuse. The child's mother reports that he was hit in the head and other body areas with a baseball bat. Upon further examination, the child's blood pressure is 84/40. What physiological action does the nurse anticipate?
Shock from bleeding points other than the head injury Shock with hypotension is rare during an isolated head injury. If a child is in shock, investigate for bleeding points other than the head.
A 10-year-old boy who was in a car wreck has been brought to the emergency room for evaluation. He appears to have suffered abdominal trauma do to his seat belt. He has tenderness in the left upper quadrant of the abdomen, especially on deep inspiration. Given these circumstances, the nurse should suspect injury to which of the following organs?
Spleen In children, the spleen is the most frequently injured organ when there is abdominal trauma, because it is usually palpable under the lower left rib. Frequent causes of injury are inappropriately applied seat belts in automobiles, handlebar injuries in bicycle accidents, or skateboard or snowboard accidents. The child will have tenderness in the left upper quadrant, of the abdomen, especially on deep inspiration, when the diaphragm moves down and touches the spleen.
The emergency department nurse is attending a 3-year-old child with a bite wound. The parents tell the nurse that the child was in the backyard playing and came into the home crying and holding his hand. They saw two puncture marks on the heel of the left hand. The father searched the yard and found no sign of any animal or reptile. The nurse notes the child is starting to have difficulty breathing, and the bite area is severely edematous. What nursing intervention is most appropriate?
Show the child pictures of animals and reptiles to identify what bit him; administer oxygen and perform a skin test to prevent a possible anaphylactic reaction to horse venom. The child or parent should attempt to describe the biting animal. Skin testing and specific antivenom should be given. Antivenom is used in the the treatment of venomous bites, the venom is diluted and injected into a horse. The horse undergoes an immun response producing antibodies against the venom's active molecule, which is used to treat the client
A 3-year-old child has sustained injuries from a fall. Once the airway is secured, what interventions would be next?
Stabilize the cervical spine.
A child is brought to the Emergency Department (ED) from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. During assessment the child verbalizes no pain in the right arm and the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's right arm?
Full-thickness A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.
