Nokea
A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?
- A. Restrain the child in the tent and notify the health care provider.
- B. Increase the oxygen concentration in the tent.
- C. Take the child out of the tent and into the playroom.
- D. Ask the mother for help in comforting the child.
Correct Answer: B
Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.
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What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?
- A. A history of diarrhea following each feeding
- B. Gastric pain evidenced by vigorous crying
- C. Poor appetite due to a poor sucking reflex
- D. An olive-shaped mass right of the midline
Correct Answer: D
Rationale: Examination of the abdomen may assist in the diagnosis and reveal key signs of hypertrophic pyloric stenosis. Visible peristaltic waves that move from left to right across the epigastric region may be evident, and palpation may reveal an olive-shaped mass in this area to the right of the midline.
When assessing the laboratory values of a child with nephrosis, the nurse anticipates which results?
- A. High levels of protein in the urine
- B. High serum lipid levels
- C. Low serum protein levels
- D. Low hemoglobin
- E. High white blood cell count
Correct Answer: A,B,C
Rationale: A patient with nephrotic syndrome has high levels of serum lipids, low serum protein, and albumin in urine that is dark and frothy with a high specific gravity. The hemoglobin and WBC are usually normal.
What should the therapeutic management of iron deficiency anemia include?
- A. Multivitamins
- B. Calcium
- C. Ferrous sulfate
- D. Iodine
Correct Answer: C
Rationale: Therapeutic management of iron deficiency anemia is iron (ferrous sulfate) supplementation, nutritional counseling, and treatment of any underlying condition.
Which is a long-term complication of cleft lip and palate?
- A. Cognitive impairment
- B. Altered growth and development
- C. Faulty dentition
- D. Physical abilities
Correct Answer: C
Rationale: The older child with cleft lip and palate may experience psychological difficulties because of the cosmetic appearance of the defect, problems with impaired speech, and faulty dentition.
The nurse is recording a history for a child who has been diagnosed with recurrent abdominal pain (RAP). What is a finding that is characteristic of this disorder?
- A. Morning headaches
- B. Pain for 3 consecutive months
- C. Febrile episodes in the late afternoon
- D. Diaphoresis when attacks occur
Correct Answer: B
Rationale: Recurrent abdominal pain occurring consecutively for 3 months supports a diagnosis of RAP once other causes have been ruled out.