After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which of the following?
Rationale:
The catheter keeps the new urethra from closing. After hypospadias repair, maintaining the urethra's patency is crucial to ensure proper healing and prevent complications. The catheter serves as a protective measure, allowing urine to flow while minimizing movement or stress on the surgical site, which is vital for successful recovery.
A: Decreases pain at the surgical site. While the catheter might indirectly contribute to comfort, its primary purpose is not pain management but rather to support urethral healing.
C: Measures his urine correctly. The catheter is not designed for accurate urine measurement; its main function is to facilitate urine drainage and maintain urethral integrity post-surgery.
D: Prevents bladder spasms. Although bladder spasms may occur post-surgery, the catheter's primary function is not to prevent spasms but to ensure the urethra remains open during the healing process.
Which of the following meals would be most appropriate for a 15-year-old with glomerulonephritis with severe hypertension?
Rationale:
Baked chicken, rice, beans, and orange juice is the most appropriate meal for a 15-year-old with glomerulonephritis and severe hypertension. This option provides low sodium, balanced nutrients, and avoids processed foods, which can exacerbate hypertension and kidney issues.
A: Egg noodles, hamburger, canned peas, milk. This choice contains high sodium and unhealthy fats, which can worsen hypertension and kidney function, making it unsuitable for the patient's condition.
B: Baked ham, baked potato, pear, canned carrots, milk. Ham is often high in sodium, potentially increasing blood pressure and straining kidney function, thus not ideal for someone with glomerulonephritis.
D: Hot dog on a bun, corn chips, pickle, cookie, milk. This option is rich in processed ingredients and sodium, which can significantly elevate blood pressure and negatively impact a patient's kidney health.
After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's disease?
Rationale:
Although our child's disease is serious, we try not to let it be the focus of our family. This statement demonstrates a balanced perspective, showcasing resilience and prioritizing family happiness over the child's asthma, which indicates positive adjustment.
A: I try to keep him happy at all costs; otherwise, he has an asthma attack. This reflects an unhealthy level of anxiety and control over the child's happiness, indicating a negative adjustment.
B: We keep our child away from other children to help cut down on infections. This suggests isolation and fear, which does not promote a healthy adjustment to managing the child's condition.
D: I'm afraid that when my child gets older, he won't be able to care for himself like I do. This reveals concerns and fear about the future, indicating a lack of confidence in the child’s independence and coping abilities.
The charge nurse on the pediatric floor has assigned a 6-year-old girl of Arab-American ethnicity with newly diagnosed type 1 diabetes and an 8-year-old girl recovering from ketoacidosis to the same semi-immune treatment. The 6-year-old's mother is upset because the parent staying with the other child is the father. The nurse should:
Rationale:
B: Reassign the children to different rooms.
This option addresses the mother's concerns regarding cultural sensitivity and parental presence. Ensuring that children from different backgrounds are not grouped together when parents have conflicting needs promotes comfort and respect for their cultural context, which is crucial in pediatric care.
A: Explain to the parents that this room arrangement facilitates teaching. This does not acknowledge the mother's discomfort and fails to prioritize the emotional and cultural needs of the children and their families.
C: Offer the Arab-American parent another place to sleep. This option could be perceived as isolating and may not address the underlying issue of the child's need for familiar support during hospitalization.
D: Refer the parent to the customer service representative. This approach seems dismissive and does not facilitate immediate resolution of the mother's concerns, potentially exacerbating the situation rather than providing compassionate support.
A father asks the nurse how he would know if his child had developed mononucleosis. The nurse explains that in addition to fatigue, which of the following would be most common?
Rationale:
Enlarged lymph glands. This symptom, along with fatigue, is a hallmark of mononucleosis, as the Epstein-Barr virus often causes significant lymphadenopathy, signaling the body's immune response to the infection.
A: Liver tenderness. While liver involvement may occur, it is not a primary symptom of mononucleosis and does not typically present prominently compared to lymphatic swelling.
C: Persistent nonproductive cough. A cough is not characteristic of mononucleosis; the condition primarily affects lymph nodes and causes fatigue rather than respiratory symptoms.
D: A blush-like generalized skin rash. Skin rashes are not commonly associated with mononucleosis, which primarily exhibits symptoms related to lymphatic swelling and systemic fatigue rather than dermatological manifestations.
A mother tells the nurse that one of her children has chickenpox and asks what she should do to care for that child. When teaching the mother, the nurse should instruct the mother to help her child prevent:
Rationale:
To prevent skin infection. Chickenpox can lead to open sores that may become infected; thus, it is crucial to keep the child’s skin clean, dry, and monitored for any signs of infection.
A: Acid-base imbalance. Chickenpox does not typically cause significant metabolic disturbances that would lead to acid-base imbalances, making this option irrelevant in the context of caring for the child.
B: Malnutrition. While nutrition is important for recovery, chickenpox primarily raises concerns about skin integrity and infection, rather than directly causing malnutrition in the affected child.
D: Respiratory infection. Although respiratory issues can arise, the immediate focus should be on preventing skin infections from the chickenpox lesions, which are more pressing in this scenario.
A school-age child with cystic fibrosis asks the nurse what sports she can become involved in as she becomes older. Which of the following activities would be appropriate for the nurse to suggest?
Rationale:
Swimming.
This activity is ideal for children with cystic fibrosis, as it promotes lung function and overall physical health while being gentle on the body. The buoyancy of water reduces stress on joints and allows for easier breathing, making it a suitable choice for aerobic exercise and respiratory health maintenance.
B: Track. This sport demands intense cardiovascular exertion, which may not be suitable for a child with cystic fibrosis due to potential breathing challenges during high-intensity activities.
C: Baseball. While enjoyable, baseball involves periods of inactivity and may not provide the continuous aerobic benefit that swimming offers, which is crucial for respiratory health in cystic fibrosis patients.
D: Javelin throwing. This activity is not recommended as it focuses more on strength and skill rather than cardiovascular fitness, which is essential for children with cystic fibrosis to manage their condition effectively.
Parents bring their child to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions should the nurse ask the parents first?
Rationale:
B: Was the infant lying on his stomach? This question is crucial as it addresses a significant risk factor for sudden infant death syndrome (SIDS), which can lead to cessation of breathing in infants.
A: Was the infant sleeping while wrapped in a blanket? While relevant, this question does not directly address the infant's position, which is vital in assessing immediate risk factors.
C: What did the infant look like when you found him? This question focuses on appearance rather than situational context, which is more critical in determining immediate risk and necessary interventions.
D: When had you last checked on the infant? This question provides background but does not directly inform the immediate circumstances that could have contributed to the child not breathing.
A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following?
Rationale:
A toddler exhibiting distress and resistance when separated from parents displays signs of protest, a common response in separation anxiety. This behavior reflects the child's unwillingness to tolerate separation, indicating emotional attachment and fear of abandonment during a vulnerable time.
B: Despair. This option suggests a passive response characterized by hopelessness, which does not align with the child's active resistance and vocal distress when attempting to leave the hospital.
C: Regression. This term describes reverting to earlier developmental behaviors, but the child's active fussing and pushing away do not indicate a return to previous states of functioning.
D: Detachment. Detachment implies emotional withdrawal and indifference, contrasting sharply with the child's visible agitation and clinginess, which demonstrate a strong emotional connection to the parents.
The nurse determines that interventions for decreasing fluid retention have been effective when the child with nephrotic syndrome demonstrates evidence of which of the following?
Rationale:
Decreased abdominal girth. A reduction in abdominal girth indicates the effective removal of excess fluid from the body, which is crucial in managing nephrotic syndrome and signifies successful intervention strategies.
B: Increased caloric intake. While nutrition is important for recovery, increased caloric intake does not directly relate to fluid retention or its management in nephrotic syndrome.
C: Increased respiratory rate. An elevated respiratory rate could signify other health issues, such as fluid overload or respiratory distress, rather than a successful reduction in fluid retention.
D: Decreased heart rate. A lower heart rate may suggest improved cardiovascular function but does not specifically indicate effective management of fluid retention in nephrotic syndrome patients.
The nurse should teach the mother of a child who has a new cast for a fractured radius to do which of the following for the first few days at home?
Rationale:
B: Have the child refrain from strenuous activities. Limiting physical exertion helps prevent complications such as additional injury or disruption of the healing process for the fractured radius during the initial recovery phase.
A: Use a hair dryer to dry the cast more quickly. This method may cause overheating or improper drying, which can compromise the integrity of the cast and the child's skin beneath it.
C: Check movement and sensation of the child's fingers once a day. Daily checks are insufficient; more frequent assessments are necessary to promptly identify any issues with circulation or nerve function.
D: Administer acetaminophen every 8 to 12 hours for discomfort. While managing pain is important, this schedule may not be adequate depending on the child's specific needs or levels of discomfort.
Two months after an adolescent's thoracic spinal cord injury, he complains of a pounding headache. The nurse notes that the client's arms and face are flushed and he is diaphoretic. What should the nurse do next?
Rationale:
Check the patency of the urinary catheter. The symptoms described, including a pounding headache and flushed face, suggest autonomic dysreflexia, often triggered by a full bladder, necessitating catheter assessment.
B: Lower the adolescent's head below his knees. This position does not address the underlying cause of autonomic dysreflexia and may not alleviate the dangerous symptoms effectively.
C: Place the adolescent flat on his back. Lying flat does not alleviate the symptoms or address the potential bladder issue, which is critical in managing autonomic dysreflexia.
D: Prepare to administer epinephrine subcutaneously. While epinephrine can address allergic reactions, it does not target the specific crisis of autonomic dysreflexia, which requires immediate identification and intervention.
A child is started on a soft diet after having been on clear liquids following an episode of severe gastroenteritis. When helping the mother choose foods for her child, which of the following foods would be most appropriate?
Rationale:
Bananas and rice. These foods are bland, easy to digest, and provide essential nutrients, making them ideal for a child recovering from gastroenteritis while transitioning from a clear liquid diet.
A: Muffins and eggs. These items may be too rich and heavy for a sensitive stomach, potentially causing discomfort during recovery from gastroenteritis.
C: Bran cereal and a bagel. High fiber content in bran may irritate the gastrointestinal tract, which is not suitable for a child post-gastroenteritis.
D: Pancakes and sausage. Greasy and heavier foods like sausage can exacerbate digestive issues, while pancakes might not provide the necessary blandness required for recovery.
When assessing for pain in a toddler, which of the following methods should be the most appropriate?
Rationale:
Observation of the child for restlessness is the most appropriate method when assessing pain in a toddler. This approach allows caregivers to identify discomfort through behavioral cues, which are often more reliable than verbal communication at this age.
A: Ask the child about the pain. Toddlers may lack the ability to articulate their feelings accurately, making verbal inquiries less effective in gauging their discomfort.
C: Use a numeric pain scale. Numeric pain scales require comprehension of numbers and abstraction, which toddlers typically do not possess, rendering this method unsuitable for their age group.
D: Assess for changes in vital signs. While vital signs can indicate distress, they do not specifically measure pain levels and may not reflect the child's subjective experience of discomfort.
The mother brings her child to the clinic after discharge from the hospital for Guillain-Barré syndrome. Which of the following statements by the mother indicates that she is following the discharge plan?
Rationale:
C: I take her to the pool where she can exercise with other children. This statement demonstrates the mother's commitment to the discharge plan by facilitating social and physical activity, which is crucial for rehabilitation after Guillain-Barré syndrome. Engaging with peers in a supportive environment enhances motivation and adherence to the prescribed exercises.
A: She and her sister argue all day. Frequent arguments may indicate a stressful environment, which can hinder the child's emotional recovery and disrupt adherence to the discharge plan.
B: I have to bribe her to get her to do her exercises. This implies a lack of intrinsic motivation for the child, suggesting that the mother struggles to encourage compliance with the recommended therapeutic activities effectively.
D: She's missed a few of her therapy sessions because she often sleeps. Missing therapy sessions reflects a significant barrier to recovery, indicating that the child may not be fully engaged in the rehabilitation process.
A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. The nurse should tell the parents to:
Rationale:
Avoid tub baths until the stent is removed.
Keeping the stent intact is crucial for healing after hypospadias repair. Tub baths can introduce bacteria, increasing infection risk or dislodging the stent, jeopardizing the child’s recovery.
B: Measure output in the urinary bag. While monitoring output is essential, the immediate concern following stent placement is protecting the stent itself rather than measuring output.
C: Avoid drinking fruit juice. There is no direct correlation between fruit juice consumption and the stent's integrity or the child's recovery process, making this advice irrelevant in this context.
D: Clean the tip of the penis 3 times a day with soap and water. Excessive cleaning could irritate the surgical site; minimal and gentle care is recommended to ensure proper healing.
When developing the plan of care for a school-age child with a suspected diagnosis of appendicitis who is complaining of severe abdominal pain, which of the following measures should the nurse expect to include in the child's plan of care?
Rationale:
C: Application of an ice bag. Ice can help reduce inflammation and alleviate pain in a child with suspected appendicitis, making it a suitable option to include in the care plan.
A: Application of a heating pad. Heat can exacerbate inflammation and may worsen the condition, which is not advisable in the case of suspected appendicitis.
B: Insertion of a rectal tube. This procedure is not relevant to managing abdominal pain associated with appendicitis and could introduce unnecessary complications or discomfort for the child.
D: Administration of an intravenous narcotic. While effective for pain relief, narcotics can mask symptoms and delay diagnosis, making their use less suitable in the initial management of suspected appendicitis.
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should:
Rationale:
Give 15 g of carbohydrate and retest the blood sugar in 15 minutes.
The 15-15 rule advises administering 15 grams of carbohydrates to quickly elevate blood sugar levels and following up with a retest after 15 minutes to ensure effectiveness, making this option correct.
A: Give 15 mL of juice and give another 15mL in 15 minutes. This suggests a volume of juice, which may not provide the necessary carbohydrate amount for effective treatment.
C: Give 15 g of carbohydrate and 15 g of protein. Protein does not rapidly raise blood sugar levels; the focus should be solely on carbohydrates for immediate intervention in hypoglycemia.
D: Give 15 oz of juice and retest in 15 minutes. This excessive volume of juice may result in over-treatment and is impractical, as the carbohydrate requirement is more critical than liquid quantity.
A mother calls the clinic to talk to the nurse. The mother states that a physician described her daughter as having 20/60 vision and she asks the nurse what this means. The nurse responds based on the interpretation that the child is experiencing which of the following?
Rationale:
C: Ability to see at 20 feet what she should see at 60 feet.
This interpretation indicates that the child's vision is impaired; she can only discern details at 20 feet that a person with normal vision can see at 60 feet, demonstrating a significant visual deficit.
A: A loss of approximately one-third of her vision.
This option miscalculates the degree of vision loss; rather than a specific loss percentage, 20/60 vision specifically describes visual acuity levels.
B: Ability to see at 60 feet what she should see at 20 feet.
This choice reverses the interpretation of visual acuity; it inaccurately represents the child's visual capabilities and suggests a level of vision superior to normal.
D: Visual acuity three times better than average.
This statement inaccurately suggests enhanced visual capacity; 20/60 does not signify superior vision but indicates a clear deficit compared to the standard measurement of 20/20 vision.
As part of a health education program, the nurse teaches a group of parents CPR. The nurse determines the teaching has been effective when a parent states:
Rationale:
If I am by myself, I should call for help before starting CPR. This statement reflects the critical first step in emergency response, emphasizing the importance of ensuring help arrives while initiating life-saving maneuvers, enhancing the victim's chances of survival.
B: I should compress the chest using 2-3 fingers. This method is insufficient for effective chest compressions, which require using the whole hand to generate adequate force for circulation.
C: I should deliver chest compression at a rate of 100 per minute. While timing is essential in CPR, the current guideline recommends a rate of 100 to 120 compressions per minute, making this statement outdated.
D: If I can't get the breaths to make the chest rise, I should administer abdominal thrusts. Abdominal thrusts are inappropriate in this context; they are intended for choking and not for addressing ineffective rescue breaths during CPR.
Which of the following statements should the nurse use to describe to the parents why their child with leukemia is at risk for infections?
Rationale:
Immature white blood cells are incapable of handling an infectious process. This indicates that the child’s immune system is compromised, making it challenging to fight off infections effectively, which is critical in managing leukemia.
A: Play activities are too strenuous. This statement does not address the immune system's capability to fight infections, focusing instead on physical exertion rather than the child's vulnerability.
B: Vitamin C intake is reduced over a period of time. While vitamin C is important for immune function, this option does not directly relate to the compromised white blood cells in leukemia.
C: The number of red blood cells is inadequate for carrying oxygen. This statement concerns anemia and oxygen transport, not the child’s susceptibility to infections, which is primarily influenced by white blood cell function.
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse's best response?
Rationale:
Newborns typically move their whole body in response to pain. This response includes general body movements and reflexive actions, indicating their discomfort and distress when experiencing painful stimuli, which provides insight into their pain perception.
A: Newborns cry and cannot be distracted to stop crying. While crying is common, distraction techniques can sometimes be effective, indicating that newborns can be momentarily diverted from pain.
B: When faced with a pain, newborns try to roll away from it. Newborns do not possess the motor skills to roll away; their responses are more reflexive and generalized than intentional movements.
D: Pain causes the newborn to withdraw the affected part. Although withdrawal can occur, it is not the primary or most characteristic reaction; overall body movement is a more general response to pain.
The parents of a preschooler ask the nurse how to handle their child's temper tantrums. Which of the following should the nurse include in the teaching plan? Select all that apply.
Rationale:
A: Putting the child in 'time-out.' This strategy provides a structured approach for the child to calm down, helping them learn self-regulation and the consequences of their actions effectively.
C: Ignoring the child. This method can reduce attention-seeking behaviors, allowing the child to understand that tantrums will not elicit a response, promoting emotional maturity over time.
B: Telling the child to go to his bedroom. This approach may isolate the child without addressing the underlying emotional needs, potentially leading to feelings of abandonment rather than resolution.
D: Putting the child to bed. This option may not be appropriate as it can confuse the child about bedtime routines and fails to address the reasons behind the tantrum.
E: Spanking the child. Physical punishment can foster fear rather than understanding, damaging the parent-child relationship and failing to teach appropriate emotional responses or coping strategies.
F: Trying to reason with the child. Attempting to negotiate during a tantrum often proves ineffective, as children in this state are typically unable to process logical arguments or instructions.
Which assessment finding in an infant with colic should the nurse prioritize?
Rationale:
D: Fever of 100.4°F. A fever in an infant with colic may indicate a potential underlying infection or serious condition requiring immediate medical evaluation, making it a priority assessment finding.
A: Frequent spitting up. While spitting up can be concerning, it is often a normal occurrence in infants and typically does not indicate a critical health issue requiring urgent attention.
B: Crying for 3 hours daily. Although prolonged crying can be distressing for parents, it is a common symptom of colic and generally not an urgent concern unless accompanied by other alarming signs.
C: Weight gain below average. Insufficient weight gain may indicate feeding issues, but it typically develops over time and is not an immediate threat compared to signs of fever.
The parent of a child with spastic cerebral palsy and a communication disorder tells the nurse, 'He seems so restless. I think he is in pain.' The nurse should:
Rationale:
Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale. This assessment tool is specifically designed for non-verbal children, allowing the nurse to evaluate pain indicators effectively, ensuring appropriate interventions can be implemented based on the child's observable behaviors and physiological responses.
B: Assess the child using the pediatric FACES scale. This scale is not suitable for non-verbal children, as it relies on self-reporting, which the child may not be able to provide.
C: Administer the pain medication which is ordered to be given as needed and assess the response. This action may not address the underlying issue, as it does not first evaluate the child's current pain level or needs.
D: Notify the primary care provider of the change in behavior. While this might be important, immediate assessment for pain is crucial to determine appropriate interventions before escalating communication to the provider.
A nurse is making an initial visit to a family with a 3-year-old child with early Duchenne's muscular dystrophy. Which of the following findings is expected with the missing child?
Rationale:
Enlarged calf muscles. In Duchenne's muscular dystrophy, the calves often become enlarged due to muscle degeneration and replacement with fatty tissue. This finding, known as pseudohypertrophy, is common in affected children and indicative of the disease's progression.
A: Contractures of the large joints. While contractures may develop over time, they are not typically seen in early stages of Duchenne's muscular dystrophy, making this finding less relevant initially.
C: Difficulty riding a tricycle. This specific skill may not be affected early on, as children with early Duchenne's muscular dystrophy can still perform many typical activities, including riding a tricycle.
D: Small, weak muscles. Initial muscle strength may be relatively preserved in early Duchenne's muscular dystrophy, with more pronounced weakness developing as the disease progresses, thus not aligning with early findings.
A 9-year-old is given morphine for postoperative pain. As the nurse is assessing the client for pain 4 hours later, his mother leaves the room and the child begins to cry. The nurse's initial assessment of the child's pain is that he is:
Rationale:
The child is less tolerant of pain because he is upset. The emotional distress from the mother's departure may heighten his perception of pain, indicating that his pain experience is influenced by psychological factors, not just the medication's effectiveness.
A: Not in pain because the crying began after the mother leaves. Crying can signify emotional distress rather than a lack of pain, especially in a postoperative setting.
C: In pain because he is crying. Crying alone does not confirm pain; it can also stem from anxiety related to the mother's absence, complicating the pain assessment.
D: Not in pain because he was medicated 4 hours ago. Medications may not provide complete relief, and individual responses to pain can vary significantly, regardless of recent medication.
After teaching the family of a child with scoliosis who wears a Boston brace, which of the following activities, if stated by the child and family as occasions appropriate for removal of the brace, indicates successful teaching?
Rationale:
When bathing, for about 1 hour per day. This indicates successful teaching as it aligns with common guidelines suggesting temporary brace removal for hygiene purposes, reflecting the family's understanding of appropriate circumstances for brace management.
B: While eating, for a total of 3 hours a day. This duration exceeds typical recommendations, suggesting a misunderstanding of brace necessity during meal times, which shouldn't require extended removal.
C: During school, for about 8 hours a day. This indicates a significant misconception, as wearing the brace during school hours is essential for maintaining spinal support and preventing progression of scoliosis.
D: When sleeping, for a total of 10 hours a day. This suggests a fundamental misunderstanding, as the brace is typically worn during sleep to maintain its corrective effect while the child is resting.
A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately:
Rationale:
Obtain the child's blood pressure. Monitoring blood pressure is crucial in glomerulonephritis as it can indicate potential complications, including hypertension, which may explain the child's headache and blurred vision.
A: Put the client to bed. While rest may be beneficial, it does not address the urgent need to assess the child's blood pressure and potential complications from glomerulonephritis.
C: Notify the physician. Although informing the physician is important, immediate assessment of the child's blood pressure is necessary to determine the severity of the situation and guide further action.
D: Administer acetaminophen (Tylenol). Pain relief may be needed, but it does not address the underlying issue; blood pressure must be evaluated first to ensure the child's safety.
The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he will not get the right care if he gets sick at college." The nurse should tell the parent:
Rationale:
Your son is going to need to learn to manage his own disease.
This response emphasizes the importance of self-management skills for the son, enabling him to navigate healthcare effectively while at college. It reassures the parent that fostering independence is crucial for his well-being, particularly in unfamiliar environments where immediate support might not be available.
A: I can have his records sent to the school's health center. While sharing records is helpful, it does not empower the son to manage his health independently in a new setting.
B: Make sure your son always carries his nephrologist's phone number. Keeping contact information handy is useful, but it does not equip him with the skills necessary for managing his condition on his own.
C: Your son can make an e-health history to facilitate his care if he gets sick away from home. Creating an e-health history is beneficial, yet it does not replace the need for him to actively manage his health.
Which of the following statements obtained from the nursing history of a toddler should alert the nurse to suspect that the child has had a febrile seizure?
Rationale:
D: The seizure occurred when the child had a respiratory infection. Febrile seizures frequently occur during episodes of illness, particularly during fevers associated with infections, making this information critical for suspicion of a febrile seizure.
A: The child has had a low-grade fever for several weeks. Prolonged low-grade fever does not typically indicate the sudden spikes in temperature associated with febrile seizures.
B: The family history is negative for convulsions. A negative family history does not eliminate the possibility of febrile seizures, which can occur even in children without a familial predisposition.
C: The seizure occurred with a necessary arrest. This statement lacks relevance to febrile seizures, as the timing of the seizure does not correlate with necessary physiological arrests in toddlers.
A recent history of which of the following should alert the nurse to gather additional information about the possibility of a urinary tract infection in a 2-year-old child who is exhibiting fever and fussiness?
Rationale:
A recent history of abdominal pain should alert the nurse to gather additional information about the possibility of a urinary tract infection in the child.
Abdominal pain may indicate discomfort associated with urinary tract issues, as infections can lead to inflammation and irritation in the bladder or kidneys. This symptom, combined with fever and fussiness, raises concern for potential urinary complications requiring further assessment.
B: Swollen lymph glands. This symptom is more indicative of systemic infections or immune responses and does not directly correlate with urinary tract infections in young children.
C: Skin rash. Skin rashes generally pertain to dermatological issues or allergic reactions, lacking a direct connection to urinary tract infections in pediatric cases.
D: Back pain. While back pain may suggest kidney involvement, it is less common in young children, making it a less relevant indicator for urinary tract infections than abdominal pain.
After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal?
Rationale:
Encouraging self-care skills in the child. Fostering self-care skills is crucial for children with Down syndrome, as it promotes independence and confidence, enabling them to participate more fully in daily life and activities.
B: Teaching the child something new each day. While this may be beneficial, the primary focus should be on self-care skills, which directly impact the child's day-to-day functioning and independence.
C: Encouraging more lenient behavior limits for the child. Setting appropriate behavior limits is essential for development, and leniency can undermine the child's learning of boundaries and self-discipline.
D: Achieving age-appropriate social skills. Although social skills are important, prioritizing self-care skills lays a foundation for independence that enhances a child's ability to engage socially in various contexts.
After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child's death is imminent. Which of the following statements offers the nurse the best guide in making plans to assist the parents in dealing with their child's imminent death?
Rationale:
Relatives are especially grieved when a child does well at first but then declines rapidly. This statement acknowledges the emotional turmoil parents face, emphasizing the shock and devastation caused by an unexpected deterioration in their child's condition, which is crucial for the nurse to understand while providing support.
A: Knowing that the prognosis is poor helps prepare relatives for the death of children. While this acknowledges the seriousness, it lacks sensitivity to the emotional complexities surrounding a child's initial improvement.
C: Trust in health care personnel is most often destroyed by a death that is considered untimely. This statement generalizes the relationship dynamics and does not address the specific grieving process parents experience in such situations.
D: It is more difficult for relatives to accept the death of an older child than that of a toddler. This comparison oversimplifies grief, overlooking the profound emotional impact regardless of the child's age or previous health status.
A 6-month old infant has had a cardiac arrest and the rapid response team has been paged. The nurse arrives in the client's room and observes a physician assistant (PA) administering CPR to an infant (see figure). To assist the PA with CPR, the nurse should:
Rationale:
Obtain an Ambu bag and give breaths at a rate of 2 breaths per 15 compressions. This approach aligns with pediatric resuscitation guidelines, ensuring effective ventilation and compressions during CPR for the infant's critical condition.
A: Tell the PA to use the heel of the hand on the infant's sternum. This method is not appropriate for infants, as it does not provide effective compression depth or ensure proper ventilation.
B: Place one hand on the infant's sternum for chest compressions while the PA ventilates the lungs at a rate of one breath to every 5 compressions. This technique does not follow recommended guidelines for infant CPR, which require more frequent breaths to ensure adequate oxygenation.
D: Encircle the infant's chest with the thumbs on top to provide compression while the PA uses an Ambu bag to administer rescue breaths after every 15 compressions. This method is incorrect; proper infant CPR requires a specific compression-to-breath ratio of 15:2 for optimal effectiveness.
When preparing to deliver back slaps to an infant who is choking on a foreign body, in which of the following positions should the nurse position the infant?
Rationale:
A: Head down and lower than the trunk. A head-down position allows gravity to assist in dislodging the foreign body from the infant's airway during back slaps, enhancing the effectiveness of this emergency technique.
B: Head up and raised above the trunk. Elevating the head can hinder gravity's role in helping to remove the obstruction, making it less effective during choking emergencies.
C: Head to one side and even with the trunk. This position does not utilize gravity to facilitate the removal of the obstruction and may complicate the process of delivering effective back slaps.
D: Head parallel to the nurse and supported at the buttocks. Maintaining the head parallel can limit the effectiveness of gravity and may not provide the best angle for performing back slaps.
A nurse is teaching a child with a food allergy about safe eating. Which instruction is most important?
Rationale:
Read food labels carefully. This instruction is crucial as it empowers the child to identify allergens in packaged foods, ensuring they make safe choices and avoid potential allergic reactions that could harm their health.
A: Eat only home-cooked meals. While home-cooked meals can be safer, they do not guarantee the absence of allergens unless ingredients are carefully monitored and assessed for safety.
C: Avoid all fruits. This is overly restrictive and unnecessary, as many fruits are safe to consume and provide essential nutrients; proper identification of safe options is key.
D: Use herbal supplements. This suggestion does not address the immediate concern of food allergies and may introduce additional risks without providing reliable safety measures for managing food intake.
After teaching the mother of a 2-year-old child with lactose intolerance about which dairy products to include in the child's diet, which of the following if stated by the mother indicates effective teaching?
Rationale:
D: Cheese. Cheese is often tolerated by individuals with lactose intolerance due to its lower lactose content compared to other dairy products. This understanding indicates that the mother has grasped effective dietary choices for her child.
A: Ice cream. Ice cream typically contains high levels of lactose, making it unsuitable for someone with lactose intolerance, revealing a misunderstanding of acceptable dairy options.
B: Creamed soups. Creamed soups often use milk or cream, which can contain significant lactose, suggesting the mother has not comprehended the implications of lactose intolerance on food choices.
C: Pudding. Pudding usually contains milk, making it a potential source of lactose, indicating that the mother may not have fully understood which dairy products are appropriate for her child.
The nurse is assisting another member of the health care team who is placing a peripherally inserted catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes the other team member has contaminated a sterile glove. The nurse should:
Rationale:
C: Tell the team member the glove is contaminated. Immediate communication is essential to maintain sterile technique during the procedure. By alerting the team member, the nurse ensures patient safety and reduces the risk of infection.
A: Discuss the incident with the team member after the event. Waiting until after the procedure may lead to further contamination and compromise patient care, which is unacceptable in a sterile environment.
B: Report the incident to the nursing unit manager. Reporting the incident does not address the immediate risk present in the current situation and delays necessary actions to protect the patient.
D: Ask the family to leave before confronting the team member. Removing the family adds unnecessary stress, detracts from the collaborative environment, and does not resolve the contamination issue at hand.
A 5-year-old child with burns on the trunk and arms has no appetite. The nurse and mother develop a plan of care to stimulate the child's appetite. Which of the following suggestions made by the mother would indicate that she needs additional teaching?
Rationale:
Withholding dessert and treats unless meals are eaten is not an effective strategy to stimulate a child's appetite. This approach can create negative associations with food and discourage eating, particularly in a child recovering from trauma like burns. Positive reinforcement and flexibility in food choices are more beneficial in promoting appetite in young children.
A: Deciding that she will feed the child herself. This approach can create a nurturing environment and ensure the child receives adequate nutrition, fostering a connection during meals.
C: Offering the child finger foods that the child likes. Finger foods can provide autonomy and make eating more enjoyable, encouraging the child to eat without pressure during recovery.
D: Serving smaller and more frequent meals. Smaller, frequent meals can help manage the child's appetite more effectively, making it easier for them to eat and digest without feeling overwhelmed.
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which of the following findings should alert the nurse to notify the physician immediately?
Rationale:
A 3-cm increase in abdominal circumference should alert the nurse to notify the physician immediately. This finding suggests possible complications such as bowel obstruction or excessive fluid accumulation, which require prompt medical intervention to prevent further issues.
B: Periods of occasional fussiness indicate that the infant may be experiencing discomfort, but this is a common post-operative behavior and does not necessitate immediate physician notification.
C: Absence of bowel sounds since surgery may be typical after colostomy creation, particularly within the first few hours, and does not inherently signal an urgent problem requiring physician intervention at this time.
D: Evidence of the infant's returning appetite is generally a positive sign, indicating recovery and does not warrant immediate attention or concern from the physician.
When observing the parent instilling prescribed ear drops ordered twice a day for a toddler, the nurse decides that the teaching about positioning of the pinna for instillation of the drops is effective when the parent pulls the toddler's pinna in which of the following directions?
Rationale:
D: Down and backward. This positioning aligns with the recommended technique for administering ear drops in toddlers, ensuring the canal is straightened for optimal medication delivery and absorption.
A: Up and forward. This direction is suitable for older children and adults, but not appropriate for toddlers, as it does not effectively align the ear canal for drop instillation.
B: Up and backward. While this direction is commonly used for older patients, it does not accommodate the anatomical differences in toddlers, hindering proper drop placement.
C: Down and forward. This method is not advisable for toddlers as it fails to provide the necessary alignment of the ear canal, which is crucial for effective medication delivery.
The nurse is caring for an infant with a temporary colostomy due to Hirschsprung's disease. Which of the following indicates proper stoma care?
Rationale:
Applying a barrier cream around the stoma is essential for protecting the skin from irritation and maintaining stoma health. This practice helps prevent complications associated with output and promotes healing during colostomy care.
A: Cleaning the stoma with alcohol can cause irritation and damage to the sensitive skin surrounding the stoma, making this practice unsuitable for proper stoma care.
B: Keeping the stoma dry and exposed may lead to skin breakdown and irritation, as moisture from output can damage the surrounding skin without appropriate protection.
D: Covering the stoma with a sterile dressing is unnecessary and may hinder airflow, potentially leading to moisture accumulation and skin complications, which are detrimental to stoma care.
After 6 months of treatment with diet and exercise, a 12-year-old with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL. The primary care provider has decided to begin metformin (Glucophage). The adolescent asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and:
Rationale:
Metformin decreases glucose production and increases insulin sensitivity. This action allows the body's cells to utilize insulin more effectively, which helps lower blood glucose levels, making it a suitable treatment for type 2 diabetes.
A: Replaces natural insulin. Metformin does not substitute for insulin; rather, it enhances how the body responds to insulin already present, rather than introducing new insulin.
B: Helps the body make more insulin. Metformin primarily focuses on improving insulin sensitivity and does not directly stimulate the pancreas to produce additional insulin.
D: Decreases carbohydrate adsorption. Metformin's mechanism does not involve the absorption of carbohydrates; it mainly works by reducing glucose production in the liver and increasing sensitivity to insulin.
After teaching the mother of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, the mother indicates that she understands her child's prognosis when she states which of the following?
Rationale:
My child has a good chance of being potty trained. This statement reflects a positive prognosis for a neonate with a repaired low anorectal anomaly, indicating that successful surgical intervention can lead to normal bowel function and independence in toilet training.
A: My child will need to wear protective pads until puberty. This statement suggests a long-term need for protection, which may not be necessary with effective management and surgical repair outcomes.
B: My child will need extra fluids to prevent constipation. While hydration is important, this statement does not capture the overall potential for normal bowel function post-surgery.
C: My child will probably always need a high-fiber diet. This implies a permanent dietary restriction, which may not be the case if bowel function normalizes after surgery.
Which dietary recommendation should the nurse include for a child with lead poisoning to enhance lead excretion?
Rationale:
Calcium-rich diet. A diet high in calcium helps to compete with lead absorption in the body, promoting lead excretion and reducing lead levels. This is crucial for children with elevated lead exposure.
A: High-protein diet. While protein is essential for growth and development, it does not significantly influence lead excretion or absorption compared to calcium's protective effects.
C: Low-fat diet. Reducing fat intake has no clear connection to lead elimination; dietary fat does not play a role in mitigating lead absorption or enhancing its excretion.
D: High-fiber diet. Although fiber is beneficial for digestion, it does not directly impact lead absorption or excretion; calcium's role is more critical in this context.
The nurse manager on a pediatric floor is reviewing national sentinel event alerts and preparing recommendations for the unit. Which strategy would help reduce pediatric medication errors? Select all that apply.
Rationale:
Utilize only oral syringes to administer oral medication, limit the size of I.V. fluid bags that can be hung on small children, and reduce the available concentrations or dose strengths to the minimum.
Using oral syringes standardizes medication administration, diminishes dosing errors, and enhances safety. Limiting I.V. fluid bag sizes ensures appropriate dosing for smaller patients, while reducing concentrations minimizes the risk of accidental overdoses.
A: Eliminate the pediatric satellite pharmacy. Removing this resource may hinder access to necessary medications, potentially leading to delays in treatment and increased risk of errors during medication administration.
B: Increase the steps in the medication administration procedure. Adding more steps could complicate the process, creating opportunities for mistakes and confusion among staff rather than promoting efficiency and accuracy in medication delivery.
A 2-year-old tells his mother he is afraid to go to sleep because 'the monsters will get him.' The nurse should tell his mother to:
Rationale:
C: Give him a favorite cuddly animal or a blanket. This option provides comfort and security, helping to alleviate fears of monsters by offering a familiar item that can soothe the child's anxiety during bedtime.
A: Allow him to sleep with his parents in their bed whenever he is afraid. This could create dependency on parental presence, preventing the child from developing independent sleeping habits and coping mechanisms.
B: Increase his activity before he goes to bed, so he eventually falls asleep from being tired. This approach may lead to overstimulation, making it harder for the child to relax and feel safe at bedtime.
D: Allow him to stay up an hour later with the family until he falls asleep. Staying up later can disrupt the child's sleep routine, potentially increasing anxiety around bedtime rather than reducing it.
Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
Rationale:
Hemorrhagic skin rash. This sign indicates potential disseminated intravascular coagulation (DIC), a serious complication of meningitis, characterized by abnormal blood clotting leading to bleeding under the skin, suggesting severe systemic involvement.
B: Edema. While edema can occur in various conditions, it is not a specific indicator of DIC and does not directly suggest coagulation abnormalities or bleeding tendencies.
C: Cyanosis. Cyanosis indicates inadequate oxygenation and is not a classic sign of DIC; it is more related to respiratory or cardiac issues rather than coagulation disturbances.
D: Dyspnea on exertion. This symptom primarily relates to respiratory difficulties and does not provide direct evidence of coagulopathy, making it less relevant in assessing for DIC in a meningitis patient.
Which of the following is appropriate language development for an 8-month-old? The child should be:
Rationale:
Saying 'dada' and 'mama' nonspecifically. At 8 months, infants typically babble and may use parental labels without associating them with specific individuals, reflecting early language skills rather than precise identification.
A: Saying 'dada' and 'mama' specifically. At this age, children are still developing their understanding of language and do not usually associate words with specific people consistently.
B: Saying three other words besides 'mama' and 'dada.' Eight-month-olds are just beginning to experiment with sounds and typically have a limited vocabulary, often focusing on these two key terms.
D: Saying 'ball' when parents point to a ball. This level of word association usually emerges later, as infants at this age are primarily engaged in babbling rather than linking words to objects.