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A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse's priority intervention?
- A. Establish a therapeutic relationship with the client
- B. Monitor the client's vital signs frequently
- C. Initiate a structured eating plan
- D. Provide education about healthy eating habits
Correct Answer: C
Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.
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Prior to discharge, the parents of a child with cystic fibrosis are demonstrating chest physiotherapy (CPT) that they will perform for their child at home. Which action requires intervention by the nurse?
- A. Plan to perform CPT when the child awakens in the morning.
- B. A cupped hand is used when percussing the lung field.
- C. A bronchodilator is administered before starting CPT.
- D. The child is placed in a supine position to begin percussion.
Correct Answer: D
Rationale: The correct answer is D. Placing the child in a supine position to begin percussion is incorrect for chest physiotherapy (CPT). This position is not effective for CPT as it may lead to improper drainage of secretions. The child should be in an appropriate sitting or slightly reclined position to ensure proper lung drainage during CPT. Choices A, B, and C are all appropriate actions for chest physiotherapy. Performing CPT when the child awakens helps in clearing secretions, using a cupped hand during percussion is a proper technique to promote secretion movement, and administering a bronchodilator before CPT can help open up the airways for better clearance.
The mother of an 11-year-old boy with juvenile arthritis tells the nurse, 'I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting.' Which information is most important for the nurse to provide this mother?
- A. Encouraging the child to rest when he experiences pain
- B. Encouraging quiet activities like watching television as a pain distractor
- C. Suggesting the use of hot baths as an alternative to pain medication
- D. Explaining that giving pain medication around the clock helps control the pain
Correct Answer: D
Rationale: The nurse should educate the mother that giving pain medication around the clock helps maintain a consistent level of pain control, preventing severe pain episodes and improving the child's quality of life. It is essential to manage pain proactively rather than waiting for the child to be in severe pain before administering medication. Choices A, B, and C do not address the importance of proactive pain management and maintaining a consistent level of pain control. Encouraging rest, quiet activities, or hot baths as distractions or alternatives may not provide adequate pain relief for the child with juvenile arthritis, and they do not address the underlying issue of effective pain management.
A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement?
- A. Obtain a specimen for blood cultures.
- B. Assess the CBC.
- C. Monitor the oral temperature every hour.
- D. Administer acetaminophen as prescribed.
Correct Answer: A
Rationale: Obtaining a specimen for blood cultures is crucial in this situation as it helps identify the source of infection, if present, and guide appropriate treatment. This is important in a child with leukemia receiving chemotherapy to prevent potential complications and ensure timely intervention. Assessing the CBC may provide overall information on the child's condition but may not specifically identify a potential infection. Monitoring the oral temperature is important but obtaining blood cultures takes precedence in this scenario. Administering acetaminophen can help reduce fever but does not address the need to identify a possible infection source.
The healthcare provider plans to screen only the highest risk children for scoliosis. Which group of children should the healthcare provider screen first?
- A. Girls between ages 10 and 14.
- B. Boys between ages 10 and 14.
- C. Boys and girls between 12 and 14.
- D. Boys and girls between 8 and 12.
Correct Answer: A
Rationale: Corrected Question: The healthcare provider plans to screen only the highest risk children for scoliosis. Which group of children should the healthcare provider screen first? Girls between ages 10 and 14 are at the highest risk for scoliosis and should be screened first as they have a higher incidence of developing scoliosis during their adolescent growth spurt. Early detection and intervention can help prevent further complications associated with scoliosis. Boys between ages 10 and 14 (choice B) are not at the highest risk compared to girls in the same age group. Boys and girls between 12 and 14 (choice C) are at a lower risk compared to girls between ages 10 and 14. Boys and girls between 8 and 12 (choice D) are at a lower risk group compared to girls between ages 10 and 14.
The healthcare provider is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture?
- A. Metabolic alkalosis.
- B. Respiratory acidosis.
- C. Metabolic acidosis.
- D. Respiratory alkalosis.
Correct Answer: A
Rationale: Pyloric stenosis leads to obstruction at the outlet of the stomach, causing frequent vomiting and loss of stomach acids. This results in a loss of hydrochloric acid and hydrogen ions, leading to metabolic alkalosis due to an increase in serum bicarbonate levels. Therefore, the correct answer is metabolic alkalosis. Choice B, respiratory acidosis, is incorrect as it is not typically associated with pyloric stenosis. Choice C, metabolic acidosis, is incorrect because the loss of stomach acids in pyloric stenosis leads to metabolic alkalosis, not acidosis. Choice D, respiratory alkalosis, is also incorrect as it is not the usual consequence of pyloric stenosis.