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A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child's body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:
- A. Rapid pulse.
- B. Decreased B/P.
- C. Pallor.
- D. Flushed Face.
Correct Answer: A,B,C
Rationale: Choice A rationale: Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body's tissues. Choice B rationale: Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure. Choice C rationale: Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale. Choice D rationale: A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.
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The Health Care Provider prescribes Amoxicillin at a dosage of 35mg/kg/dose for a child who weighs 34 lbs. and has Otitis Media. The medication is available in a suspension of 50 mg/ml. What is the total daily dosage in ml for this child?
- A. 10 ml
- B. 20 ml
- C. 30 ml
- D. 40 ml
Correct Answer: A
Rationale: Step 1 is to convert the child's weight from pounds to kilograms. This is done by dividing the weight in pounds by 2.2, so 34 lbs ÷ 2.2 = 15.45 kg. Step 2 is to calculate the dose in mg. This is done by multiplying the weight in kg by the dosage per kg, so 15.45 kg × 35 mg/kg = 540.75 mg. Step 3 is to convert the dose in mg to ml. This is done by dividing the dose in mg by the concentration of the medication in mg/ml, so 540.75 mg ÷ 50 mg/ml = 10.815 ml. So, the total daily dosage in ml for this child is approximately 10.82 ml, rounded to the nearest hundredth as required.
A nurse is contributing to the plan of care of an unconscious adolescent who ingested a non-corrosive substance that has no recommended antidote. The nurse should recommend performing gastric lavage with which of the following substances?
- A. Activated charcoal
- B. Osmotic diarrheal agents
- C. Syrup of ipecac
- D. 0.9% sodium chloride
Correct Answer: A
Rationale: Activated charcoal is often used in the management of poisoning. It works by binding to the poison in the stomach and preventing it from being absorbed into the body. Osmotic diarrheal agents are not typically used in gastric lavage. These agents work by increasing the amount of water in the intestinal tract, which can stimulate bowel movements. Syrup of ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended for use in poisoning cases. 0.9% sodium chloride, or normal saline, is a type of fluid that's often used in medical treatments, but it's not typically used in gastric lavage for poisoning.
A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?
- A. Mucus and blood in stools.
- B. Increased appetite.
- C. Jaundice.
- D. Drooling.
Correct Answer: A
Rationale: Mucus and blood in stools, often described as 'currant jelly' stools, are a common symptom of intussusception. Increased appetite is not typically associated with intussusception. In fact, children with this condition may experience decreased appetite due to abdominal pain. Jaundice is not a symptom of intussusception. Jaundice, a yellowing of the skin and eyes, is more commonly associated with liver conditions. Drooling is not a typical symptom of intussusception. Symptoms of intussusception are primarily gastrointestinal, including abdominal pain and bloody stools.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Place a pillow under the child's head.
- B. Remove the child's eyeglasses.
- C. Time the seizure.
- D. Move the child into a side-lying position.
Correct Answer: D
Rationale: While placing a pillow under the child's head might seem like a good idea, it's actually not recommended during a seizure. The child's movements could be unpredictable, and a pillow could potentially cause suffocation. Removing the child's eyeglasses is a good idea, but it's not the first thing you should do. The child's safety is the top priority, and eyeglasses can be removed once the child is safe. Timing the seizure is important for medical professionals to know, but it's not the first action to take. The child's immediate safety is the priority. Moving the child into a side-lying position is the priority. This position helps keep the airway clear and allows any vomit to exit the mouth, reducing the risk of choking.
A nurse is assisting with collecting data from a 10-month-old in the emergency department. Medical History: Guardians brought the infant to the emergency room after witnessing the infant's arms and legs shaking. The infant did not respond to the guardians' voices during that time. The episode lasted approximately 5 min and the infant was sleeping soundly afterwards. On the way to the emergency department, the infant had another episode of shaking of the extremities and drooling. The infant was asleep when they arrived for evaluation. The infant has no prior medical or surgical history. Born full-term at 40 weeks to a birth mother who had regular prenatal visits. Actions to Take: Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Potential Condition
- B. Parameters to Monitor 1
- C. Parameters to Monitor 2
- D. Vitamin
- E. Blood pressure
Correct Answer: A
Rationale: The infant's symptoms suggest a possible seizure disorder. Seizures can cause symptoms such as shaking of the extremities and unresponsiveness. The fact that the infant was sleeping soundly after the episode and had another episode of shaking and drooling on the way to the emergency department further supports this. The nurse should monitor the infant's neurological status and vital signs, and administer anticonvulsant medication as ordered by the physician.