What nursing intervention is appropriate when caring for an ...

[chandani]

What nursing intervention is appropriate when caring for an unconscious child?
 
  a. Avoid using narcotics or sedatives to provide comfort and pain relief.
  b. Change the child's position infrequently to minimize the chance of increased intracranial pressure (ICP).
  c. Monitor fluid intake and output carefully to avoid fluid overload and cerebral edema.
  d. Give tepid sponge baths to reduce fevers above 38.3 C (101 F) because antipyretics are contraindicated.

Question 2

What test is never performed on a child who is awake?
 
  a. Doll's head maneuver
  b. Oculovestibular response
  c. Assessment of pyramidal tract lesions
  d. Funduscopic examination for papilledema

[IRincones]

Answer to Question 1

ANS: C
Often comatose patients cannot cope with the quantity of fluids that they normally tolerate. Overhydration must be avoided to prevent fatal cerebral edema. Narcotics and sedatives should be used as necessary to reduce pain and anxiety, which can increase ICP. The child's position should be changed frequently to avoid complications such as pneumonia and skin breakdown. Antipyretics are the method of choice for fever reduction.

Answer to Question 2

ANS: B
The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on an awake child or one who has a ruptured tympanic membrane. The doll's head maneuver, assessment of pyramidal tract lesions, and funduscopic examination for papilledema are not considered painful and can be performed on awake children.

[chandani]

TYSM

[Liddy]

Thanks for the timely response, appreciate it