Nokea
A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?
- A. Immobilize the affected limb
- B. Apply ice to the affected area
- C. Elevate the affected limb
- D. Check the child's neurovascular status
Correct Answer: A
Rationale: The priority nursing action when a child with a suspected fracture is brought to the emergency department is to immobilize the affected limb. Immobilization helps prevent further injury until a fracture is confirmed or ruled out. Applying ice or elevating the limb may be necessary interventions but should come after immobilizing the limb. Checking the child's neurovascular status is important but should follow immobilization to ensure no further harm is done during the assessment.
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What is the priority intervention for a child with acute laryngotracheobronchitis upon admission?
- A. Pad the side rails of the crib.
- B. Arrange for a quiet, cool room.
- C. Place a tracheotomy set at the bedside.
- D. Obtain a recliner for a parent to stay.
Correct Answer: C
Rationale: The correct priority intervention for a child with acute laryngotracheobronchitis is to place a tracheotomy set at the bedside. Acute laryngotracheobronchitis can lead to airway obstruction, making it essential to have the equipment readily available in case of emergency. Padding the side rails, arranging for a quiet room, or obtaining a recliner for a parent are not the immediate priorities in managing a child with this condition.
A child with a diagnosis of appendicitis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?
- A. Administering antibiotics
- B. Maintaining strict NPO status
- C. Encouraging fluid intake
- D. Monitoring for signs of infection
Correct Answer: B
Rationale: The correct preoperative intervention for a child with appendicitis scheduled for surgery is maintaining strict NPO (nothing by mouth) status. This is crucial to reduce the risk of aspiration during anesthesia induction and prevent potential complications during surgery. Administering antibiotics may be a part of the treatment plan but is not a preoperative intervention. Encouraging fluid intake is contraindicated preoperatively to avoid delays in surgery and complications related to anesthesia. Monitoring for signs of infection is important postoperatively to assess for any complications that may arise due to the surgical procedure.
A parent arrives in the emergency clinic with a 3-month-old baby who has difficulty breathing and prolonged periods of apnea. Which assessment data should alert the nurse to suspect shaken baby syndrome (SBS)?
- A. Birth occurred before 32 weeks' gestation
- B. Lack of stridor and adventitious breath sounds
- C. Previous episodes of apnea lasting 10 to 15 seconds
- D. Retractions and use of accessory respiratory muscles
Correct Answer: D
Rationale: Retractions and the use of accessory respiratory muscles are signs of respiratory distress in infants. These clinical manifestations can be associated with trauma, such as shaken baby syndrome (SBS), which can lead to severe head injuries and respiratory compromise. Birth before 32 weeks' gestation (Choice A) is more related to prematurity complications rather than SBS. The absence of stridor and adventitious breath sounds (Choice B) may not be specific indicators of SBS. Previous episodes of apnea lasting 10 to 15 seconds (Choice C) alone may not be as concerning as the presence of retractions and use of accessory muscles in the context of a distressed infant.
An 8-year-old child diagnosed with meningitis is to undergo a lumbar puncture. What should the nurse explain is the purpose of this procedure?
- A. To measure the pressure of cerebrospinal fluid
- B. To obtain a sample of cerebrospinal fluid for analysis
- C. To relieve intracranial pressure
- D. To assess the presence of infection in the spinal fluid
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain a sample of cerebrospinal fluid for analysis. This fluid is then examined for signs of infection, bleeding, or other abnormalities. Measuring the pressure of cerebrospinal fluid is typically done during the procedure itself, but it is not the primary purpose of the lumbar puncture. While a lumbar puncture can indirectly help relieve intracranial pressure by removing excess cerebrospinal fluid, this is not its primary purpose. Assessing the presence of infection in the spinal fluid is part of the analysis that follows the collection of the sample, making it a secondary outcome of the procedure.
A child with a diagnosis of appendicitis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?
- A. Administering antibiotics
- B. Maintaining strict NPO status
- C. Encouraging fluid intake
- D. Monitoring for signs of infection
Correct Answer: D
Rationale: The correct preoperative intervention for a child with appendicitis scheduled for surgery is to monitor for signs of infection. This is crucial to ensure that any potential infections are promptly identified and managed before surgery. Administering antibiotics, maintaining strict NPO status, and encouraging fluid intake are important interventions in various clinical situations but are not the priority in this scenario. Administering antibiotics may be part of the treatment plan but is typically prescribed by a physician. Maintaining NPO status is important to prevent complications related to anesthesia but may not directly address the specific needs of a child with appendicitis. Encouraging fluid intake is generally beneficial for hydration but may not be the primary concern before surgery for appendicitis.