Published - Thu, 23 Feb 2023

NCLEX-RN Exam Questions - Part 138

1. A 2-year-old boy fell out of bed and has a subdural hematoma. When his mother leaves him for the first time, you will expect the child to:

A) Be comforted when he is held
B) Cry
C) Not notice that his mother has left
D) Withdraw and become listless

2. The doctor has ordered a restricted fluid intake for a 2- year-old child with a head injury. Normal fluid intake for a child of 2 years is:

A) 900 mL/24 hr
B) 1300 mL/24 hr
C) 1600 mL/24 hr
D) 2000 mL/24 hr

3. A 2-year-old child with a scalp laceration and subdural hematoma of the temporal area as a result of falling out of bed should be prevented from:

A) Crying
B) Falling asleep
C) Rolling from his back to his tummy
D) Sucking his thumb

4. A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:

A) Encourage him to drink plenty of fluids
B) Expect him to have nausea with vomiting
C) Keep him awake for the next 12 hours
D) Wake him up every 1 - 2 hours during the night

5. A 14-year-old boy fell off his bike while 'popping a wheelie' on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:

A) Ask the physician to order a sedative
B) Have the client describe his headache every 15 minutes
C) Increase his fluid intake to 3000 mL/24 hr
D) Offer diversionary activities

1. Right Answer: B
Explanation: (A) It will be difficult to comfort a 2 year old with a headache without his mother. (B) This baby probably will cry, which should be prevented because it will increase his intracranial pressure (ICP). Asking the mother to wait until the baby is asleep may help. (C) An awake 2 year old will notice when his mother leaves. (D) An older child may withdraw when feeling afraid, but a 2 year old will probably show more aggressive behavior.

2. Right Answer: C
Explanation: (A, B, D) These values are incorrect. Normal intake for a child of 2 years is about 1600 mL in 24 hours. (C) This value is correct. Normal intake for a child of 2 years is about 1600 mL in 24 hours.

3. Right Answer: A
Explanation: (A) A child with a subdural hematoma has increased ICP. Crying may significantly increase this pressure. (B) Adequate sleep is essential, but it is important that the child can be aroused from sleep after head injury. (C) This child is free to roll from his back to his abdomen. (D) Thumb-sucking serves to reduce anxiety and should not be prevented at this time.

4. Right Answer: D
Explanation: (A) Fluid intake should be normal. Fluid intake may be restricted when there is a risk for increased ICP in a hospitalized client. (B) Nausea is possible, but vomiting without nausea is more likely with increased ICP. Neither one should be expected, but the mother should know to notify the physician or hospital if they occur. (C)The child does not need to be kept awake. It is important that he can be aroused from sleep. (D) If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.

5. Right Answer: D
Explanation: (A) CNS depressants are not given for headache due to head injury because they would mask changes in neurological status and because they could further depress the CNS. (B) The client should not be asked to think about his headache every 15 minutes. (C) Fluid intake should be normal or restricted for a client with a head injury. Normal fluid intake for a 14 year old is about 20002400 mL daily. (D) Diversion may help the child to focus on a pleasant activity instead of on his headache.

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