Nokea
A 2-year-old child who was admitted to the hospital for further surgical repair of a clubfoot is standing in the crib, crying. The child refuses to be comforted and calls for the mother. As the nurse approaches the crib to provide morning care, the child screams louder. Knowing that this behavior is typical of the stage of protest, what is the most appropriate nursing intervention?
- A. Use comforting measures while holding the child.
- B. Fill the basin with water and bathe the child.
- C. Sit by the crib and bathe the child later when the anxiety decreases.
- D. Postpone the bath for a day because a child this upset should not be traumatized further.
Correct Answer: C
Rationale: During the stage of protest, children may display distress when separated from their primary caregiver. Sitting by the crib and providing comfort when the child is less anxious is an appropriate intervention. Choice A is incorrect because attempting to hold the child while they are in distress may escalate the situation. Choice B is inappropriate as it ignores the child's emotional distress and proceeds with a task that can wait. Choice D is not the best option as postponing the bath for a day is not necessary; instead, addressing the child's emotional needs promptly is crucial in this situation.
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A child with a diagnosis of congenital heart disease is admitted to the hospital. What should the nurse include in the child's care plan?
- A. Monitoring fluid status
- B. Encouraging activity
- C. Promoting a high-calorie diet
- D. Maintaining oxygen therapy
Correct Answer: A
Rationale: Monitoring fluid status is crucial for a child with congenital heart disease because these children are at risk of fluid overload which can worsen their condition. Monitoring fluid intake and output helps prevent complications like congestive heart failure. Encouraging activity (Choice B) should be individualized based on the child's condition and tolerance, as excessive activity can strain the heart. Promoting a high-calorie diet (Choice C) is not typically recommended for children with congenital heart disease unless specifically indicated, as excessive weight gain can worsen their cardiac function. Maintaining oxygen therapy (Choice D) may be necessary in some cases, but monitoring fluid status is a more fundamental aspect of care for children with congenital heart disease.
When the working mother of a toddler is preparing to take her child home after a prolonged hospitalization, she asks the nurse what type of behavior she should expect to be displayed. What is the nurse's most appropriate description of her child's probable behavior?
- A. Excessively demanding behavior
- B. Hostile attitude toward the mother
- C. Cheerful, with shallow attachment behaviors
- D. Withdrawn, without emotional ties to the mother
Correct Answer: A
Rationale: After a prolonged hospitalization, a toddler may exhibit excessively demanding behavior as they readjust to being home. This behavior can be a result of the child seeking extra attention and reassurance after a stressful experience. Choices B, C, and D are incorrect because hostility, cheerfulness with shallow attachment, and withdrawal without emotional ties are less likely outcomes in this situation and do not align with common reactions of toddlers after hospitalization.
The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults?
- A. Most childhood cancers affect tissues rather than organs.
- B. Childhood cancers are usually localized when found.
- C. Unlike adult cancers, childhood cancers are less responsive to treatment.
- D. The majority of childhood cancers can be prevented.
Correct Answer: A
Rationale: The correct answer is A. Most childhood cancers, such as leukemias and sarcomas, affect tissues rather than specific organs, unlike many adult cancers. Choice B is incorrect because childhood cancers can be localized or spread, similar to adult cancers. Choice C is incorrect because childhood cancers can be highly responsive to treatment, especially when diagnosed early. Choice D is incorrect because the majority of childhood cancers cannot be prevented as they are often due to genetic mutations or unknown causes.
A parent calls the outpatient clinic requesting information about the appropriate dose of acetaminophen for a 16-month-old child who has signs of an upper respiratory tract infection and fever. The directions on the bottle of acetaminophen elixir are 120 mg every 4 hours when needed. At the toddler's 15-month visit, the healthcare provider prescribed 150 mg. What is the nurse's best response to the parent?
- A. "The dose is close enough, and it doesn't really matter which one is given."
- B. "From your description, the medication is not necessary. It should be avoided at this age."
- C. "It is appropriate to use dosages based on age. Children typically have weights consistent for their age groups."
- D. "The prescribed dose of the drug was based on weight, and this is a more accurate way of determining a therapeutic dose."
Correct Answer: D
Rationale: The most accurate way to determine a therapeutic dose for children is based on their weight rather than age. Weight-based dosing accounts for individual variations in drug metabolism and distribution, ensuring a more precise and safer medication administration. Choices A, B, and C are incorrect as they do not address the importance of weight-based dosing in children, potentially leading to inappropriate dosing and safety concerns.
A child with a diagnosis of gastroenteritis is admitted to the hospital. What is the priority nursing intervention?
- A. Monitoring fluid and electrolyte balance
- B. Encouraging regular exercise
- C. Administering antipyretics
- D. Administering antibiotics
Correct Answer: A
Rationale: The correct answer is monitoring fluid and electrolyte balance. Gastroenteritis is characterized by inflammation of the gastrointestinal tract leading to diarrhea and vomiting, which can result in dehydration and electrolyte imbalances. Therefore, the priority nursing intervention is to monitor and maintain the child's fluid and electrolyte balance to prevent complications. Encouraging regular exercise (Choice B) may not be appropriate initially for a child with gastroenteritis who needs rest and fluid replacement. Administering antipyretics (Choice C) is not the priority unless the child has a fever. Administering antibiotics (Choice D) is not indicated for viral gastroenteritis, which is the most common cause of the condition.