A school-aged child develops a nosebleed (epistaxis). Which action should the nurse take?
Keep the child flat and apply pressure to the bridge of the nose.
Turn the child’s head to the side and press on the nasal ridge.
Sit the child upright and apply pressure to the sides of the nose.
Elevate the head of the bed slightly and apply pressure to the forehead.
The Correct Answer is C
Choice A rationale
Keeping the child flat and applying pressure to the bridge of the nose is not effective for managing a nosebleed. The child should be in an upright position to reduce blood flow to the nose and prevent swallowing blood.
Choice B rationale
Turning the child’s head to the side and pressing on the nasal ridge is not the recommended approach for managing a nosebleed. The child should be in an upright position with pressure applied to the sides of the nose.
Choice C rationale
Sitting the child upright and applying pressure to the sides of the nose is the correct action. This position helps to reduce blood flow to the nose and applying pressure helps to stop the bleeding.
Choice D rationale
Elevating the head of the bed slightly and applying pressure to the forehead is not effective for managing a nosebleed. The child should be in an upright position with pressure applied to the sides of the nose to stop the bleeding. .
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Correct Answer is D
Explanation
Choice A rationale
A low-carbohydrate, low-protein diet is not appropriate for a child with acute glomerulonephritis. Carbohydrates and proteins are essential nutrients, and restricting them can lead to malnutrition and other complications.
Choice B rationale
A regular diet with no added salt is not sufficient for managing acute glomerulonephritis with peripheral edema. Sodium restriction is necessary to help reduce fluid retention and edema.
Choice C rationale
A low-protein, low-potassium diet is not the best choice for managing acute glomerulonephritis. While protein and potassium intake may need to be monitored, the primary focus should be on sodium and fluid restriction.
Choice D rationale
A low-sodium, fluid-restricted diet is the correct choice. Sodium restriction helps reduce fluid retention and edema, while fluid restriction helps manage fluid balance and prevent further complications.
Correct Answer is C
Explanation
Choice A rationale
The conjunctivae, the mucous membranes that cover the front of the eye and line the inside of the eyelids, can show signs of cyanosis. However, they are not the most reliable indicator of central cyanosis. Central cyanosis is best observed in areas with a rich blood supply and thin skin, where the bluish discoloration due to low oxygen levels in the blood is more apparent.
Choice B rationale
The soles of the feet are not a reliable indicator of central cyanosis. Peripheral cyanosis, which affects the extremities, can occur due to poor circulation or cold temperatures and does not necessarily indicate central cyanosis. Central cyanosis is more accurately assessed in areas with a high concentration of blood vessels and thin skin.
Choice C rationale
The oral mucosa, including the lips and tongue, is the most reliable indicator of central cyanosis. This area has a rich blood supply and thin skin, making it easier to observe the bluish discoloration caused by low oxygen levels in the blood. Central cyanosis is a sign of significant hypoxemia and requires prompt medical attention.
Choice D rationale
The ear lobes are not the most reliable indicator of central cyanosis. While they can show signs of cyanosis, they are not as accurate as the oral mucosa. The ear lobes may be affected by peripheral cyanosis, which can occur due to factors like cold temperatures or poor circulation, rather than central cyanosis.