Which medication should the nurse expect to administer to a child with an acute sickle cell pain crisis?
- A. Meperidine (Demerol)
- B. Morphine
- C. Acetaminophen (Tylenol)
- D. Ibuprofen (Motrin)
Correct Answer: B
Rationale: In the management of acute sickle cell pain crisis in children, morphine is the preferred medication due to its effectiveness in providing pain relief. Meperidine (Demerol) is less commonly used in this scenario because of its potential for neurotoxicity with repeated doses. Acetaminophen (Tylenol) and Ibuprofen (Motrin) are not typically sufficient for managing the severe pain associated with sickle cell crises and are not the first-line treatment options.
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The nurse is caring for a patient from a culture unfamiliar to the local area. The best way for a culturally competent nurse to interact with the family is to:
- A. Explain that the child must now be cared for differently
- B. Speak in the language most used by the staff and encourage the family to learn it
- C. Be respectful and open-minded when discussing beliefs
- D. Insist that the family changes their beliefs
Correct Answer: C
Rationale: The best way for a culturally competent nurse to interact with a family from an unfamiliar culture is to be respectful and open-minded when discussing beliefs. This approach demonstrates cultural competence by honoring and valuing the family's beliefs and practices. Choice A is incorrect as it disregards the family's cultural practices without understanding them. Choice B is not the best approach as it focuses on language rather than respecting beliefs. Choice D is inappropriate as it goes against the principles of cultural competence by imposing beliefs on the family.
According to Erikson's theory of psychosocial development, the school-age child is in which stage?
- A. Industry vs. inferiority
- B. Autonomy vs. shame and doubt
- C. Identity vs. role diffusion
- D. Trust vs. mistrust
Correct Answer: A
Rationale: The correct answer is A: 'Industry vs. inferiority.' According to Erikson's theory, school-age children (approximately 6-12 years old) are in the stage of industry vs. inferiority. In this stage, children focus on developing a sense of competence and productivity. Choice B, 'Autonomy vs. shame and doubt,' is incorrect as it refers to the stage that occurs during early childhood (1-3 years old). Choice C, 'Identity vs. role diffusion,' pertains to adolescence (12-18 years old). Choice D, 'Trust vs. mistrust,' is related to the stage of infancy (0-1 year old). Therefore, option A is the most appropriate stage for school-age children in Erikson's theory.
An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?
- A. Jaundice
- B. Hyperactive bowel sounds
- C. Absence of sucking, vomiting
- D. Coughing, with excessive secretion
Correct Answer: D
Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.
What is a common significant side effect of opioid administration?
- A. Euphoria
- B. Diuresis
- C. Constipation
- D. Allergic reactions
Correct Answer: C
Rationale: Constipation is one of the most common side effects of opioid administration due to the slowing down of gastrointestinal motility. Opioids affect the bowel movements, leading to constipation. Euphoria, while a possible effect, is less common than constipation. Diuresis is not a typical side effect of opioids; instead, urinary retention may occur. Allergic reactions are rare side effects of opioids, with symptoms such as rash, itching, or anaphylaxis.
The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?
- A. Infiltration is not solely related to the activity level of VLBW infants.
- B. Continuous infusion pumps do not always stop automatically when infiltration occurs.
- C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
- D. The infusion site should be checked regularly to prevent infiltration-related complications.
Correct Answer: C
Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.