In: Nursing
36. A nurse in an emergency department is assessing an adolescent who reports inhalation of gasoline. Which of following findings should the nurse expect?
a. Hypothermia
b. Ataxia
c. Hyperactive reflexes
d. Pinpoint pupils
37. A nurse is planning care for a school-age child who was admitted from the emergency department 2 hrs ago. Which of the following interventions should the nurse include to promote adequate sleep for the child?
a. Follow the child’s home sleep routine to reduce anxiety
b. Allow the child to adjust their bedtime to promote autonomy
c. Leave the lights on in the child’s room to promote safety
d. Provide the child with video games prior to bedtime to reduce stress
38. A nurse is assessing an infant who has severe dehydration due to gastroenteritis. Which of the following findings should the nurse expect?
a. Capillary refill for 2 seconds
b. Increased urine output
c. Increased respiratory rate
d. Hypertension
43. A nurse is preparing to collect a urine specimen from a female infant using a urine collection bag. Which of the following actionjs should the nurse take?
a. Place a snug-fitting diaper over the drainage bag
b. Stretch the perineum taut when applying the bag
c. Apply lidocaine gel to the perineum before attaching the bag
d. Position the opening of the bag over the urethra and the
53. A nurse in the emergency department is caring for a child who has a temperature of 39.1oC (102.4oF) and a suspected diagnosis of bacterial meningitis. Which of the following actions should the nurse take first?
a. Prepare the child for a lumbar puncture
b. Administer an antipyretic to the child
c. Implement droplet precautions for the child
d. Dim the lights in the child’s room
Question No:36
Correct answer is option-b
Rationale
Gasoline is a liquid which is volatile and flammable . It can be colorless or pale brown to pink in color with a characteristic smell. The common method of exposure is Inhalation and skin or eye contact and ingestion are less common routes. Adverse systemic effects of this substance are mainly due to CNS insults and pulmonary injury.
The commonly occurring features of gasoline inhalation are:
Central nervous system |
Staggering or ataxia (loss of balance) Dizziness Headache Facial flushing Slurring of speech Blurring of vision Weakness Seizures Coma |
Pulmonary |
Breathing difficulty Coughing Wheezing |
Cardiovascular |
Cardiac arrhythmias Cardac failure |
Other options are incorrect because gasoline is a mild irritant to skin and eyes and hypothermia, hyperactive reflexes and pinpoint pupils will not occur with its inhalation.