A patient is unable to control his bowels ff. a subarachnoid hemorrhage. Which intervention by the nurse can help reduce episodes of bowel incontinence?

Correct Answer: C

Rationale: Option C, which is to toilet the patient according to his pre-illness schedule, whether or not he feels the urge, is the best intervention by the nurse to help reduce episodes of bowel incontinence in this patient with subarachnoid hemorrhage. This strategy can help establish a routine and promote regular bowel movements, which may reduce the likelihood of bowel incontinence episodes. Asking the patient frequently if he has to have a bowel movement (Option A) may not be effective, as the patient may not always be able to accurately communicate their needs due to the underlying condition. Placing incontinence pads on the patient's bed and chair (Option B) may manage the consequences of incontinence but does not address the root cause. While taking care not to embarrass the patient when incontinent episodes occur (Option D) is important for maintaining the patient's dignity, it does not directly address the issue of reducing bowel incontinence episodes.

Correct Answer: C

Rationale: Elevating the head of the bed is an important intervention to help prevent complications in patients with impaired respiratory function. By elevating the head of the bed, gravity assists in improving lung expansion and ventilation, making breathing easier for the patient. This position promotes better airflow and can help reduce the risk of respiratory complications such as aspiration. It is a non-invasive and simple intervention that can be easily implemented in a home care setting to support the patient's respiratory function and overall well-being. Antibiotics, bedrest, and scheduled suctioning are not directly related to improving respiratory function in this context.

Correct Answer: D

Rationale: Inhalation of carbogen (a mixture of carbon dioxide and oxygen) for a short period is recommended for various reasons in pediatric patients. The correct answer, option D, "All of the above," is correct because carbogen can stimulate respiration, dilate blood vessels, and dislodge blood clots. Carbogen stimulates respiration by increasing the levels of oxygen in the body, which can help in situations where there is respiratory distress. It dilates blood vessels by increasing blood flow and oxygen delivery to tissues, which can be beneficial in conditions like vascular insufficiency. Carbogen can also help dislodge blood clots by improving blood flow and oxygenation, potentially preventing serious complications like stroke. Options A, B, and C are incorrect because they do not encompass the comprehensive effects of carbogen inhalation. While they touch on some individual benefits, the correct option, D, provides a holistic view of the advantages of using carbogen in pediatric patients. In an educational context, understanding the effects of carbogen inhalation is crucial for nursing students preparing for the NCLEX-RN exam. It reinforces the importance of knowing the pharmacological actions of common medications and treatments used in pediatric care, highlighting the multifaceted benefits of interventions like carbogen inhalation in clinical practice.

Correct Answer: D

Rationale: A normal corneal light reflex, also known as the Hirschberg test, is assessed by shining a light into the patient's eyes and observing the reflection of the light on the corneas. In a normal response, the light should be reflected at the same spot in both eyes. If the light is off-center in one eye compared to the other, it could indicate a deviation in the alignment of the eyes, known as strabismus. Therefore, choice D, "Light is reflected at the same spot in both eyes," is the correct indicator of a normal corneal light reflex.

Correct Answer: B

Rationale: The most common site for ear infections is the middle ear. This area is prone to infections, especially in children, due to the Eustachian tube being shorter and more horizontal compared to adults. The middle ear is connected to the upper respiratory tract, allowing bacteria or viruses to easily travel and cause infections in this area. Symptoms of a middle ear infection include ear pain, fluid buildup, and possible hearing loss. Treatment may involve antibiotics and pain relief medications, and in some cases, surgical intervention may be necessary to drain the fluid.