Nokea
A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?
- A. Bilateral bronchial breath sounds.
- B. Diaphragmatic respiration.
- C. A resting respiratory rate of 35 breaths per minute.
- D. Flaring of the nares.
Correct Answer: D
Rationale: Flaring of the nares is a classic sign of acute respiratory distress in infants. It indicates increased work of breathing and is a visible cue that the child is struggling to breathe. This finding should alert healthcare providers to the severity of the respiratory distress and the need for prompt intervention to support the child's breathing.
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An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test that was drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?
- A. Ask when the adolescent was last seen at the clinic
- B. Tell the mother to have the teenager call the clinic
- C. Provide the mother with the findings
- D. Explain that the information cannot be released without the 18-year-old's permission
Correct Answer: D
Rationale: When an individual turns 18, they are legally considered an adult, and privacy laws mandate that their consent is required before sharing their medical information with others. It is important to respect the adolescent's autonomy and privacy rights by explaining to the mother that the information cannot be disclosed without the 18-year-old's permission.
An adolescent female who is leaning forward with her hands on her knees to breathe tells the practical nurse that she has been using triamcinolone (Azmacort) inhalation aerosol before coming to the clinic. Which action should the PN implement?
- A. Obtain vital signs and assess breath sounds for wheezing.
- B. Collect a blood sample for white blood cell count.
- C. Give the client a nebulizer breathing treatment.
- D. Administer another dose of Azmacort.
Correct Answer: A
Rationale: When a patient presents with breathing difficulties, the first action should be to assess vital signs and breath sounds to evaluate the severity of the condition. This assessment will provide crucial information to determine the appropriate course of action and treatment. Collecting a blood sample for a white blood cell count, giving a nebulizer treatment, or administering another dose of Azmacort would not be the initial priority in this situation.
A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Encourage a variety of large portions of food at every meal.
- B. Allow the child to eat any food desired and tolerated.
- C. Recommend eating the food as siblings eat at home.
- D. Restrict food brought from fast food restaurants.
Correct Answer: B
Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention for a child with altered nutrition due to anorexia, nausea, and vomiting. It is crucial to prioritize maintaining adequate nutritional intake, and by allowing the child to choose foods they desire and can tolerate, the chances of improving their nutritional status increase. This approach helps in ensuring that the child receives necessary nutrients during chemotherapy, even if their appetite is affected by the treatment.
What is the nurse's best response when a 2-year-old boy begins to cry as the mother starts to leave?
- A. Let me read this book to you.
- B. Two-year-olds usually stop crying the minute the parent leaves.
- C. Now be a big boy. Mommy will be back soon.
- D. Let's wave bye-bye to mommy.
Correct Answer: D
Rationale: The best response for the nurse in this situation is to help the child understand that the separation is temporary. Waving bye-bye to mommy can be reassuring to the child and make the separation process easier. It acknowledges the child's feelings while providing a positive and comforting interaction.
During a well-baby exam, a nurse finds that a 2-month-old's right testicle is not descended into the scrotum, but the left one is palpable. What should the nurse do?
- A. Ask if the right testis has been seen in the scrotum before
- B. Address potential concerns about future fertility
- C. Schedule an ultrasound to confirm the position of the testicle
- D. Prepare to obtain a urine specimen for culture
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.