Nokea
A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child?
- A. It is unnecessary because of child's age.
- B. It is essential because it will be an adjustment.
- C. Preparation is not needed because the colostomy is temporary.
- D. Preparation is important because the child needs to deal with negative body image.
Correct Answer: B
Rationale: Preparation is essential even for a young child, as they need to adjust to the temporary colostomy and understand the changes to their body, which can be confusing and distressing without proper explanation.
You may also like to solve these questions
What signs and symptoms are indicative of a urinary tract disorder in the infancy period (1-24 months)? (Select all that apply.)
- A. All below
- B. Poor feeding
- C. Hypothermia
- D. Frequent urination
Correct Answer: A
Rationale: In infants, urinary tract disorders may present with poor feeding, hypothermia, and frequent urination. Pallor can be associated with other conditions but is less specific to urinary tract disorders.
What is the most effective method to prevent infection in the newborn?
- A. Using disposable items
- B. Practicing proper hand hygiene by staff and family
- C. Administering prophylactic antibiotics
- D. Isolating the newborn from others
Correct Answer: B
Rationale: The most effective method to prevent infection in newborns is by practicing proper hand hygiene by staff and family. This is crucial as it helps reduce the transmission of infectious agents, protecting vulnerable newborns. Using disposable items may help, but proper hand hygiene is more effective. Administering prophylactic antibiotics without a specific indication can lead to antibiotic resistance and is not recommended. Isolating the newborn from others is not practical and may not be necessary if proper hand hygiene is maintained.
What findings on physical assessment of a neonate would indicate the need for further evaluation?
- A. Nystagmus
- B. Epstein pearls
- C. Low-set ears
- D. Positive Babinski reflex
Correct Answer: C
Rationale: Low-set ears in a neonate suggest major abnormalities and should prompt further evaluation. The correct alignment of the top of the pinnae of the ear with the outer canthus of the eye is crucial. Nystagmus, an involuntary eye movement, is common in newborns and often resolves on its own. Epstein pearls, small cysts on the hard palate, are insignificant and disappear over time. A positive Babinski reflex is normal in infants up to 1 year of age. Therefore, the presence of low-set ears is the most concerning finding that requires immediate attention.
A 12-year-old child is injured in a bicycle accident. When considering the possibility of renal trauma, the nurse should consider what factor?
- A. Flank pain rarely occurs in children with renal injuries.
- B. Few nonpenetrating injuries cause renal trauma in children.
- C. Kidneys are immobile, well protected, and rarely injured in children.
- D. The amount of hematuria is not a reliable indicator of the seriousness of renal injury.
Correct Answer: D
Rationale: The amount of hematuria is not a reliable indicator of the severity of renal trauma, as even minor injuries can cause significant bleeding, while severe injuries may result in little or no visible blood. Renal trauma should be evaluated through imaging and clinical assessment.
Which teaching point should the nurse include when providing education to an adolescent client who participates in soccer regarding the plan of care for diabetes mellitus?
- A. Decreased food intake
- B. Increased doses of insulin
- C. Increased food intake
- D. Decreased doses of insulin
Correct Answer: C
Rationale: The correct teaching point the nurse should include is to advise the adolescent client who participates in soccer to increase food intake. Physical activity increases glucose utilization, so adolescents with diabetes need to consume additional carbohydrates to prevent hypoglycemia during and after exercise. Choice A (Decreased food intake) is incorrect because the adolescent needs extra carbohydrates to support the increased physical activity. Choice B (Increased doses of insulin) is incorrect as the focus should be on adjusting food intake rather than insulin doses. Choice D (Decreased doses of insulin) is also incorrect as the insulin doses should be adjusted based on the increased food intake and physical activity level.