Nokea
When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?
- A. Change the insertion site every 24 hours.
- B. Check the insertion site frequently for signs of infiltration.
- C. Use a macrodropper to facilitate reaching the prescribed flow rate.
- D. Avoid restraining the child to prevent undue emotional stress.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation?
- A. Water excess
- B. Sodium excess
- C. Water depletion
- D. Potassium excess
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?
- A. Monitor closely for signs of infection.
- B. Place the child with the operative side of the head up.
- C. Avoid pumping the shunt reservoir to maintain patency.
- D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.
Correct Answer: A
Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.
The nurse suspects that a child has ingested some type of poison. What clinical manifestation would be most suggestive that the poison was a corrosive product?
- A. Tinnitus
- B. Disorientation
- C. Stupor, lethargy, and coma
- D. Edema of the lips, tongue, and pharynx
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
How is masturbation in the pre-school child viewed?
- A. Abnormal behavior that needs to be dealt with immediately
- B. Disruptive to the family
- C. Normal behavior that can best be dealt with by ignoring and providing distraction
- D. Embarrassing to the parents
Correct Answer: C
Rationale: Masturbation in preschool children is a normal behavior as they explore their bodies. It is best viewed as a natural part of development. Parents are often advised to ignore it and provide distractions rather than making the child feel ashamed or embarrassed. Choice A is incorrect because it is a natural behavior and not considered abnormal in this context. Choice B is incorrect as it does not necessarily disrupt the family. Choice D is incorrect as the focus should be on the child's development and well-being, not on the parents' feelings of embarrassment.
When checking the intravenous (IV) site on a child, the nurse should take which action?
- A. Look at the site.
- B. Ask the child if the site hurts.
- C. Look at the site while palpating the area.
- D. Take all the tape off, assess the site, and redress.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.