The nurse working in an urgent care center admits a 5-year-old ...

[futuristic]

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.

Question 2

The nurse is caring for a client with severe diarrhea, nausea and vomiting. Expected findings upon physical assessment and review of laboratory studies include:(Select all that apply) Standard Text: Select all that apply.
 
  1. Increased breathing
  2. Change in level of consciousness
  3. pH below 7.35
  4. pH above 7.35
  5. Low bicarbonate level

[GCabra]

Answer to Question 1

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.

Answer to Question 2

1,2,3,5
Rationale: The respiratory system increases breathing to try to blow off excess acid