Nokea
A 10-year-old girl is living with a foster family. Which intervention is the priority for the child in this family structure?
- A. Determining if the child is being bullied at school
- B. Dealing with mixed expectations of parents
- C. Establishing who is the child's actual caretaker
- D. Performing a comprehensive health assessment
Correct Answer: D
Rationale: Performing a comprehensive health assessment is crucial for a child living with a foster family as they may have moved between different homes, leading to incomplete medical records. This assessment helps identify any existing health issues, ensure appropriate care, and address any unmet health needs. While addressing issues like bullying or parental expectations is important, the immediate priority should be ensuring the child's overall health and well-being. Establishing the actual caretaker is also important but may not be as urgent as addressing potential health concerns.
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After corrective surgery for hypertrophic pyloric stenosis (HPS), what should the nurse teach a parent to do immediately after a feeding to limit vomiting?
- A. Rock the infant.
- B. Place the infant in an infant seat.
- C. Place the infant flat on the right side.
- D. Keep the infant awake with sensory stimulation.
Correct Answer: B
Rationale: After corrective surgery for hypertrophic pyloric stenosis (HPS), placing the infant in an infant seat is the correct action to take immediately after feeding to limit vomiting. This position helps keep the head elevated, reducing the risk of vomiting. Rocking the infant (Choice A) may agitate the stomach and increase the likelihood of vomiting. Placing the infant flat on the right side (Choice C) is not recommended as it does not encourage proper digestion and may increase the risk of vomiting. Keeping the infant awake with sensory stimulation (Choice D) does not address the positioning concern related to vomiting in this specific post-operative scenario.
When compensating for increased physical activity, what should the nurse teach a child with type 1 diabetes to do?
- A. Eat more food when planning to exercise more than usual.
- B. Take oral, not injectable insulin, on days of heavy exercise.
- C. Take insulin in the morning when extra exercise is anticipated.
- D. Eat foods that contain sugar to compensate for the extra exercise.
Correct Answer: A
Rationale: The correct answer is to 'Eat more food when planning to exercise more than usual.' Increased physical activity requires more energy, so additional food intake is necessary to prevent hypoglycemia. Choice B is incorrect because the method of insulin administration should not be altered based on physical activity. Choice C is incorrect as insulin timing should be consistent rather than based on anticipated exercise. Choice D is incorrect since relying on foods with sugar can lead to unstable blood sugar levels, which is not ideal for managing diabetes during exercise.
What should be the priority action when caring for a child with acute laryngotracheobronchitis?
- A. Initiate measures to reduce fever.
- B. Ensure delivery of humidified oxygen.
- C. Provide support to reduce apprehension.
- D. Continually assess the respiratory status.
Correct Answer: D
Rationale: When caring for a child with acute laryngotracheobronchitis, the priority action should be to continually assess the respiratory status. This is crucial to detect early signs of respiratory distress, such as worsening stridor or increased work of breathing. Prompt intervention can prevent further deterioration of the child's condition. Initiating measures to reduce fever (Choice A) may be necessary but is not the priority in this situation. Ensuring delivery of humidified oxygen (Choice B) is important for maintaining oxygenation but should follow the assessment of respiratory status. Providing support to reduce apprehension (Choice C) is also important for the child's comfort but is not the priority over assessing and managing respiratory distress.
What should be the priority action when caring for a child with acute laryngotracheobronchitis?
- A. Initiate measures to reduce fever.
- B. Ensure delivery of humidified oxygen.
- C. Provide support to reduce apprehension.
- D. Continually assess the respiratory status.
Correct Answer: D
Rationale: The priority action when caring for a child with acute laryngotracheobronchitis is to continually assess the respiratory status (Option D). Acute laryngotracheobronchitis can potentially lead to respiratory distress, making continuous monitoring crucial to identify early signs of deterioration and intervene promptly. While options A, B, and C are also important aspects of care, they do not take precedence over respiratory assessment in this critical situation. Initiating measures to reduce fever (Option A), ensuring oxygen delivery (Option B), and providing emotional support (Option C) are all significant interventions, but without ongoing assessment of respiratory status, there is a risk of missing potential respiratory deterioration.
What should be included in the preoperative teaching for a 4-year-old child scheduled for a tonsillectomy?
- A. Explaining the procedure in detail
- B. Encouraging deep breathing exercises
- C. Discussing the importance of hydration
- D. Using play therapy to prepare the child
Correct Answer: B
Rationale: Encouraging deep breathing exercises is important preoperative teaching for a child scheduled for a tonsillectomy. Deep breathing exercises can help the child relax and reduce anxiety, which is beneficial before the procedure. Explaining the procedure in detail might be overwhelming for a 4-year-old, whereas encouraging deep breathing exercises can be more beneficial in promoting relaxation and preparing the child. Discussing the importance of hydration is crucial for postoperative care but may not be the priority for preoperative teaching. Using play therapy can help prepare the child, but encouraging deep breathing exercises is more directly related to relaxation and preparation for the procedure.