Nokea
The nurse is caring for a 1-month-old girl with low-set ears and severe hypotonia who was diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?
- A. Interrupted family process related to the child's diagnosis
- B. Deficient knowledge related to the genetic disorder
- C. Grieving related to the child's poor prognosis
- D. Ineffective coping related to stress from providing care
Correct Answer: C
Rationale: The correct nursing diagnosis would be 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience feelings of grief and loss when dealing with such a diagnosis. The choice 'Interrupted family process' does not directly address the emotional response to the prognosis. 'Deficient knowledge' may be a concern but does not address the emotional aspect of dealing with a poor prognosis. 'Ineffective coping related to stress from providing care' focuses more on the caregiver's ability to cope rather than the family's response to the child's condition.
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What is the priority nursing responsibility when a 3-year-old child in a crib is experiencing a tonic-clonic seizure with a clamped jaw?
- A. Apply restraints.
- B. Administer oxygen.
- C. Protect the child from self-injury.
- D. Insert a plastic airway in the child's mouth.
Correct Answer: C
Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints (Choice A) can cause harm by restricting movement during the seizure. While administering oxygen (Choice B) may be necessary, it is not the immediate priority during an active seizure. Inserting a plastic airway (Choice D) is contraindicated as it can lead to injury and is not recommended during a seizure. Protecting the child from self-injury (Choice C) is crucial to prevent harm from uncontrolled movements and potential falls, ensuring the safety of the child.
While caring for a 5-year-old child hospitalized for the treatment of acute lymphoblastic leukemia (ALL), what is the priority nursing intervention?
- A. Administering antibiotics
- B. Preventing infection
- C. Providing nutritional support
- D. Managing pain
Correct Answer: B
Rationale: The priority nursing intervention for a child with acute lymphoblastic leukemia (ALL) is preventing infection due to their compromised immune system. Children undergoing treatment for ALL are highly susceptible to infections, making infection prevention crucial for the child's well-being and treatment success. Administering antibiotics, though important in specific cases, is not the priority in this scenario. Providing nutritional support and managing pain are significant aspects of care but take a back seat to infection prevention in this situation.
A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?
- A. Monitoring for signs of infection
- B. Providing nutritional support
- C. Monitoring for signs of bleeding
- D. Monitoring for signs of pain
Correct Answer: A
Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, putting the child at a higher risk of developing infections. Early detection of signs of infection is crucial to prevent serious complications and initiate timely treatment. Providing nutritional support is important for overall health but is not the priority when the child is at risk of infection. Monitoring for signs of bleeding is essential, but infection surveillance takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of pain is important for comfort but is not the priority over infection prevention and management.
A nurse on the pediatric unit is observing the developmental skills of several 2-year-old children in the playroom. Which child should the nurse continue to evaluate?
- A. Cannot stand on one foot
- B. Builds a tower of 7 blocks
- C. Uses echolalia when speaking
- D. Colors outside the lines of a picture
Correct Answer: C
Rationale: The correct answer is C. Using echolalia, which is the repetition of words or phrases, is not typical for a 2-year-old child and may indicate the need for further evaluation. Choices A, B, and D are all within the expected developmental skills for a 2-year-old. While most 2-year-olds may not be able to stand on one foot, it is not a cause for concern at this age. Building a tower of 7 blocks and coloring outside the lines of a picture are both appropriate for a 2-year-old's developmental skills.
A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?
- A. Monitoring for signs of infection
- B. Providing nutritional support
- C. Monitoring for signs of bleeding
- D. Monitoring for signs of pain
Correct Answer: A
Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, increasing the risk of infections. Detecting and managing infections promptly is crucial to prevent complications and improve outcomes. Providing nutritional support is important, but infection prevention takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of bleeding is relevant in leukemia due to decreased platelet count, but infection surveillance is more critical. Monitoring for signs of pain is essential, but addressing infections promptly is the priority to prevent further deterioration in the child's condition.