Question

Six-month-old Casey Martin and her 4-year-old brother, John Martin sustain head injuries when the car driven by their mother is struck head on at an intersection. Although Casey is in an infant seat, her head is severely shaken. John unbuckles his car seat and his head strikes the dash board with force.

Instructions: While taking this case study, all questions must be answered correctly before you will be able to proceed to the next page. For all incorrect answers, select a new response and click the Next button. When all questions have been answered correctly, clicking the Next button will display the next page.

The Martins are transported to the emergency department (ED) where Mrs. Martin is treated and released. The children are triaged as needing immediate intervention.

Question

Safe and effective care: Nursing care planning

The nurse develops a plan of care for casey. Care is complex due to the severity of her injury and large size of the hematoma.

6. while providing care for a child with an epidural hematoma which nursing intervention are most essentials? (select all that apply)

A. maintain the airway and monitor oxygen saturation

B. administer antibiotics as ordered

C. frequent neurological assessment

D. implement seizure precaution

E. monitor fluid status and osmolarity

(Note: I tried to select all but failed. One of them is incorrect not sure which)

Answer 1

While caring the patient with head injury, always elevate the head end of the patient.The most important complication in head injury is increased intra cranial pressure. So the first and foremost nursing action when caring the head injury patient is raise the head end of the patient to reduce intra cranial pressure.

Maintain airway is very important in all the patients for survival. Always keep in mind ABC as like in CPR. Airway is always very first important to maintain in all the patients for breathing.There by maintain oxygen saturation to identify adequate supply of oxygen to vital organs and other organs and tissues.

Antibiotics administration is essential for the head injury patient. When the head is injured, there is more chance for the entry of microbes, there by developing infection.So in order to avoid infection, administration of antibiotics is essential.

For all neurological disorder patients, neurological assessment is important to identify early neurological problems and improvement in neurological status.

Implementing seizure precautions are also essential in dealing with emergency. Precautionary measures are helping if seizure occurs.

The incorrect option is maintain fluid status and osmolarity. Because increased fluid volume will increase the intracranial pressure.In dealing with head injury patient, fluid status maintainence will increase the intra cranial pressure.So keep this in mind, will direct you to option E as wrong option among others.