Nokea
A child with a diagnosis of gastroenteritis is admitted to the hospital. What is the priority nursing intervention?
- A. Monitoring fluid and electrolyte balance
- B. Encouraging regular exercise
- C. Administering antipyretics
- D. Administering antibiotics
Correct Answer: A
Rationale: The correct answer is monitoring fluid and electrolyte balance. Gastroenteritis is characterized by inflammation of the gastrointestinal tract leading to diarrhea and vomiting, which can result in dehydration and electrolyte imbalances. Therefore, the priority nursing intervention is to monitor and maintain the child's fluid and electrolyte balance to prevent complications. Encouraging regular exercise (Choice B) may not be appropriate initially for a child with gastroenteritis who needs rest and fluid replacement. Administering antipyretics (Choice C) is not the priority unless the child has a fever. Administering antibiotics (Choice D) is not indicated for viral gastroenteritis, which is the most common cause of the condition.
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A parent brings a 2-month-old infant with Down syndrome to the pediatric clinic for a physical and administration of immunizations. Which clinical finding should alert the nurse to perform a further assessment?
- A. Flat occiput
- B. Small, low-set ears
- C. Circumoral cyanosis
- D. Protruding furrowed tongue
Correct Answer: C
Rationale: Circumoral cyanosis should alert the nurse to perform a further assessment because it may indicate inadequate oxygenation or circulation, potentially related to cardiac or respiratory issues. Flat occiput (choice A) is a common finding in infants and is not typically concerning. Small, low-set ears (choice B) are common in Down syndrome and not specifically indicative of an acute issue requiring immediate further assessment. Protruding furrowed tongue (choice D) is also commonly seen in infants with Down syndrome and typically does not warrant immediate further assessment unless associated with other concerning signs or symptoms.
The parents of a newborn with phenylketonuria (PKU) need help and support in adhering to specific dietary restrictions. They ask the nurse, "How long will our child have to be on this diet?" How should the nurse respond?
- A. "We are still not sure; you should discuss this with your health care provider."
- B. "If your baby does well, foods containing protein can gradually be introduced."
- C. "Your child needs to be on this diet at least through adolescence and into adulthood."
- D. "This is a lifelong problem, and it is recommended that dietary restrictions must be continued."
Correct Answer: D
Rationale: The correct answer is D: "This is a lifelong problem, and it is recommended that dietary restrictions must be continued." PKU requires a lifelong adherence to a specific diet low in phenylalanine to prevent cognitive and developmental issues. Phenylalanine buildup can lead to irreversible damage, making it crucial for individuals with PKU to maintain dietary restrictions throughout their lives. Choices A, B, and C are incorrect because they do not address the lifelong nature of dietary restrictions necessary for PKU management.
The nurse is teaching a group of parents about the side effects of immunization vaccines. Which sign should the nurse include when discussing an infant receiving the Haemophilus influenzae (Hib) vaccine?
- A. Lethargy
- B. Urticaria
- C. Generalized rash
- D. Low-grade fever
Correct Answer: D
Rationale: The correct answer is 'D. Low-grade fever.' A low-grade fever is a common and mild side effect of the Hib vaccine, indicating that the immune system is responding to the immunization. Lethargy (choice A) can be a sign of more serious adverse effects and should be monitored closely but is not typically associated with the Hib vaccine. Urticaria (choice B) and generalized rash (choice C) are less common side effects of the Hib vaccine compared to low-grade fever.
A child with a diagnosis of nephrotic syndrome is being treated with corticosteroids. What is an important nursing consideration?
- A. Monitor for signs of infection
- B. Monitor blood pressure
- C. Monitor for hyperglycemia
- D. Monitor for hypertension
Correct Answer: A
Rationale: When a child with nephrotic syndrome is undergoing treatment with corticosteroids, it is crucial to monitor for signs of infection. Corticosteroids can suppress the immune system, increasing the child's susceptibility to infections. Monitoring for signs of infection allows for early detection and prompt intervention, reducing the risk of complications. While monitoring blood pressure (choice B) is important in nephrotic syndrome, it is not the most immediate concern when the child is on corticosteroids. Monitoring for hyperglycemia (choice C) is relevant in corticosteroid therapy, but the priority in this scenario is to watch for signs of infection. Monitoring for hypertension (choice D) is important in nephrotic syndrome but is not the most critical consideration when the child is on corticosteroids.
During an oral cavity assessment of a 6-month-old infant, the parent inquires about which teeth will erupt first. How should the healthcare provider respond?
- A. Incisors
- B. Canines
- C. Upper molars
- D. Lower molars
Correct Answer: A
Rationale: Incisors are the teeth that typically erupt first in infants, usually around 6 months of age. These teeth play a crucial role in biting and cutting food. Canines, upper molars, and lower molars are not the primary teeth to erupt in infants. Canines usually erupt after incisors, while molars, whether upper or lower, come in later during the teething process.