A nurse is caring for a 10-year-old child with a brain injury. On ...

[SGallaher96]

A nurse is caring for a 10-year-old child with a brain injury. On assessing the child, the nurse finds the following data: opens eyes only to pain, mutters inappropriate words, has abnormal extension to stimulation. Which action by the nurse takes priorit
 
  A.
  Alert the operating room for emergent surgery.
  B.
  Document the findings; reassess in 15 minutes.
  C.
  Notify the provider; prepare for intubation.
  D.
  Raise the head of the child's bed to 45 .

Question 2

A student nurse is preparing to give a 48.5-lb(22-kg) child IV mannitol (Osmitrol). What action by the student causes the nursing instructor to intervene?
 
  A.
  Assesses child's pain including report of headache
  B.
  Confirms the dose of 66 g in a 20 solution
  C.
  Double-checks child's urine output for the shift
  D.
  Explains to the child that nausea may occur

[mjenn52]

Answer to Question 1

ANS: C
A child with a Glasgow Coma Score of less than 8 needs to be intubated and mechanically ventilated. This child's score is 7 (eye opening = 2, verbal response = 3, motor response = 2). The child may need an invasive procedure due to the increased intracranial pressure, but this would not take priority over managing the airway and providing adequate oxygenation. The findings need to be documented, but further action is needed. Raising the head of the bed may or may not be beneficial, but does not take priority over intubation.

Answer to Question 2

ANS: B
Mannitol is an osmotic diuretic often used to decrease intraocular pressure. The correct dose is 1-2 g/kg, so the safe dose range is 22-44 g. The nurse would intervene if the student prepared to administer 66 g. The other actions are appropriate.