A head-injured patient, who opens eyes to painful stimuli, is confused & localizes to pain. His Glasgow coma score is:

Correct Answer: B

Rationale: In pediatric nursing, understanding the Glasgow Coma Scale (GCS) is crucial for assessing a child's level of consciousness after a head injury. In this scenario, the patient opens eyes to painful stimuli, is confused, and localizes to pain. These responses indicate a GCS score of 9 (Option B). The correct answer (B) is right because a GCS score of 9 reflects a moderate level of consciousness impairment. The patient is responding to painful stimuli and localizing the source of pain, which indicates a higher level of neurological function compared to options A, C, and D. Option A (7) is incorrect because a GCS score of 7 indicates a more severe level of impairment, with a patient likely not localizing pain. Option C (1) is incorrect as a GCS score of 1 signifies no response, indicative of deep unconsciousness. Option D (13) is incorrect as this score would suggest a fully alert and oriented patient, which is not the case in the given scenario. Educationally, understanding GCS scoring helps nurses accurately assess and monitor pediatric patients with head injuries. It guides clinical decision-making and helps determine the appropriate level of care needed for each patient. It is essential for nurses to interpret GCS scores correctly to provide optimal care and ensure positive patient outcomes.

Correct Answer: A

Rationale: In the context of pediatric nursing, dilutional hyponatremia is a condition characterized by low sodium levels in the blood due to excess water retention. The correct answer, option A) Heart failure, is associated with dilutional hyponatremia because in heart failure, the body retains excess fluid which dilutes the sodium concentration in the blood. Option B) Respiratory failure does not directly cause dilutional hyponatremia. Respiratory failure leads to inadequate oxygenation rather than fluid retention. Option C) Nutritional edema is unrelated to dilutional hyponatremia as it refers to swelling due to protein deficiency, not sodium imbalance. Option D) Inadequate breastfeeding in infants can lead to dehydration or electrolyte imbalances, but not dilutional hyponatremia specifically. In an educational context, understanding the causes and manifestations of dilutional hyponatremia is crucial for pediatric nurses to provide safe and effective care to children with fluid and electrolyte imbalances. Recognizing the underlying conditions that can lead to dilutional hyponatremia, such as heart failure, is essential for timely intervention and appropriate treatment to prevent complications.

Correct Answer: C

Rationale: In pediatric nursing, understanding the correct rate of chest compressions during CPR is crucial for saving infants' lives. The ideal rate of chest compression during CPR in infants is 100 per minute (Option C). This rate is recommended by the American Heart Association (AHA) for effective circulation and oxygenation. Option A (150 per minute) is too fast for infants and may not allow for adequate chest recoil, affecting blood flow. Option B (125 per minute) is also too fast and can lead to ineffective compressions. Option D (75 per minute) is too slow and may not generate enough force to circulate blood effectively. Educationally, it is important to teach healthcare providers the correct rate of chest compressions in infants to ensure they are prepared to respond in emergency situations. Understanding and practicing these guidelines can make a significant difference in the outcomes of pediatric patients in cardiac arrest. By reinforcing these principles through test questions, educators can help solidify this essential knowledge among students and healthcare professionals.

Correct Answer: D

Rationale: In pediatric nursing, understanding advanced life support is crucial for providing optimal care in emergency situations. The correct answer, option D, "Treatment of life-threatening arrhythmias," is not typically included in the immediate interventions of advanced life support for pediatric patients. Vascular access (option A) is important for administering medications or fluids rapidly in emergency situations. Fluid administration (option B) is vital for maintaining adequate perfusion and addressing hypovolemia. Breathing support (option C) is essential to ensure adequate oxygenation and ventilation. In an educational context, it's important to emphasize that while treating life-threatening arrhythmias is crucial in advanced cardiac life support, in pediatric patients, other interventions such as establishing vascular access, providing fluids, and ensuring proper breathing support take precedence in the initial stages of resuscitation. This distinction is critical to prevent delays in life-saving interventions and optimize outcomes for pediatric patients in emergency situations.

Correct Answer: B

Rationale: In pediatric nursing, understanding the signs and symptoms of shock is crucial for early identification and intervention. In the context of early (compensated) shock, the correct feature is tachycardia (Option B). Tachycardia is a compensatory mechanism the body employs to maintain perfusion and oxygen delivery to vital organs in response to decreased blood volume or pressure. Hypotension (Option A) is a feature of late (decompensated) shock when compensatory mechanisms fail. Decreased level of consciousness (Option C) and cold extremities (Option D) are also signs of late-stage shock when the body is unable to maintain perfusion adequately. Educationally, understanding the progression of shock from compensated to decompensated stages is vital for nurses caring for pediatric patients. Recognizing early signs like tachycardia can prompt timely interventions to prevent further deterioration and improve outcomes. This knowledge equips nurses to assess, intervene, and communicate effectively in emergency situations, ensuring the best possible care for pediatric patients in shock.