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When planning care for a child diagnosed with rheumatic fever, what is the primary goal of nursing care?
- A. Reduce fever.
- B. Maintain fluid and electrolytes.
- C. Prevent cardiac damage.
- D. Maintain joint mobility and function.
Correct Answer: C
Rationale: The primary goal of nursing care for a child diagnosed with rheumatic fever is to prevent cardiac damage. Rheumatic fever can lead to complications affecting the heart, making it crucial to monitor and prevent cardiac involvement to avoid long-term consequences. While addressing fever and joint pain are important aspects of care, preventing cardiac damage takes precedence in managing rheumatic fever.
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During a well-baby check of a 7-month-old infant, the practical nurse notes an absence of babbling. Which focused assessment should the PN implement?
- A. Visual function.
- B. Auditory function.
- C. Cognitive function.
- D. Social development.
Correct Answer: B
Rationale: The absence of babbling in a 7-month-old infant is a concerning auditory development milestone. Babbling is an early stage of language development which involves making various sounds. A lack of babbling could indicate a hearing impairment or other auditory issues. Therefore, the practical nurse should focus on assessing the infant's auditory function to determine if further evaluation or intervention is necessary.
A 7-year-old child with a history of asthma is brought to the emergency department with an acute asthma exacerbation. The child is wheezing and using accessory muscles to breathe. What is the nurse's priority intervention?
- A. Administer a nebulized bronchodilator
- B. Obtain an arterial blood gas
- C. Start the child on oxygen therapy
- D. Notify the healthcare provider
Correct Answer: A
Rationale: In a 7-year-old child with an acute asthma exacerbation showing signs of wheezing and increased work of breathing, the priority intervention for the nurse is to administer a nebulized bronchodilator immediately. Bronchodilators help dilate the airways, relieve bronchospasm, and improve breathing, which is crucial in managing an acute asthma attack and preventing further respiratory distress.
A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?
- A. Describe the side-lying, knees to chest position that must be assumed during the procedure.
- B. Tell the child to expect loud clicking noises during the procedure that may be slightly annoying.
- C. Reassure the child that there will be no restrictions on activity after the procedure is completed.
- D. Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A mother brings her school-aged daughter to the pediatric clinic for evaluation of her anti-epileptic medication regimen. What information should the nurse provide to the mother?
- A. The medication dose will be tapered over a period of 2 weeks when being discontinued
- B. If seizures return, multiple medications will be prescribed for another 2 years
- C. A dose of valproic acid (Depakote) should be available in the event of status epilepticus
- D. Phenytoin (Dilantin) and phenobarbital (Luminal) should be taken for life
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the nurse's best response when a 2-year-old boy begins to cry as the mother starts to leave?
- A. Let me read this book to you.
- B. Two-year-olds usually stop crying the minute the parent leaves.
- C. Now be a big boy. Mommy will be back soon.
- D. Let's wave bye-bye to mommy.
Correct Answer: D
Rationale: The best response for the nurse in this situation is to help the child understand that the separation is temporary. Waving bye-bye to mommy can be reassuring to the child and make the separation process easier. It acknowledges the child's feelings while providing a positive and comforting interaction.