Nokea
A 6-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV). What should the nurse include in the care plan?
- A. Providing small, frequent feedings
- B. Administering antibiotics
- C. Maintaining strict isolation
- D. Elevating the head of the bed
Correct Answer: D
Rationale: Elevating the head of the bed is essential in the care of an infant with RSV as it helps improve breathing by reducing congestion and promoting drainage. This position also aids in maintaining patent airways and can enhance comfort for the infant. Providing small, frequent feedings (Choice A) is generally appropriate for infants but is not a specific intervention for RSV. Administering antibiotics (Choice B) is not indicated for RSV, as it is a viral infection and antibiotics are ineffective against viruses. Maintaining strict isolation (Choice C) is important to prevent the spread of infections, but it is not a direct care intervention for managing RSV symptoms.
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A nurse is discussing the care of an infant with colic with the parents. What should the nurse explain is the cause of colicky behavior?
- A. Inadequate peristalsis
- B. Paroxysmal abdominal pain
- C. An allergic response to certain proteins in milk
- D. A protective mechanism designed to eliminate foreign proteins
Correct Answer: B
Rationale: The correct answer is B: Paroxysmal abdominal pain. Colic in infants is characterized by paroxysmal abdominal pain, leading to excessive crying and fussiness. It is not caused by inadequate peristalsis (Choice A), an allergic response to certain proteins in milk (Choice C), or a protective mechanism designed to eliminate foreign proteins (Choice D). Understanding that colic is primarily associated with abdominal pain helps healthcare providers provide appropriate care and support to parents dealing with colicky infants.
The child has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management?
- A. Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered.
- B. Use guided imagery and therapeutic touch.
- C. Administer meperidine as ordered.
- D. Initiate pain assessment with a standardized pain scale.
Correct Answer: D
Rationale: Initiating pain assessment with a standardized pain scale is crucial in managing pain effectively during a sickle cell crisis. This step allows the nurse to objectively evaluate the child's pain level and tailor the pain management plan accordingly. Administering medication without a proper assessment could lead to inappropriate pain management. Using guided imagery and therapeutic touch may be beneficial as adjunct therapies but should not replace the initial pain assessment. Meperidine is not typically the first-line choice for pain management in sickle cell crisis due to its potential for neurotoxic metabolites.
.A nurse is caring for an infant whose vomiting is intractable. For what complication is it most important for the nurse to assess?
- A. Acidosis
- B. Alkalosis
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What explanation should be given to a parent about the purpose of a tetanus toxoid injection for their child?
- A. Passive immunity is conferred for life.
- B. Long-lasting active immunity is conferred.
- C. Lifelong active natural immunity is conferred.
- D. Passive natural immunity is conferred temporarily.
Correct Answer: B
Rationale: The correct answer is B: 'Long-lasting active immunity is conferred.' Tetanus toxoid injection provides long-lasting active immunity by stimulating the body to produce its own antibodies. Choice A is incorrect because tetanus toxoid injection does not provide passive immunity. Choice C is incorrect because the immunity conferred by the vaccine is not natural but artificially induced. Choice D is incorrect as the immunity provided by the tetanus toxoid injection is active, not passive.
A nurse is assessing a 2-year-old child with suspected Down syndrome. What characteristic physical feature is the nurse likely to observe?
- A. Epicanthal folds
- B. Webbed neck
- C. Enlarged head
- D. Polydactyly
Correct Answer: A
Rationale: Epicanthal folds are a distinctive physical feature commonly observed in individuals with Down syndrome. These are horizontal skin folds that cover the inner corners of the eyes. Webbed neck (choice B) is not typically associated with Down syndrome but can be seen in conditions like Turner syndrome. Enlarged head (choice C) is not a characteristic feature of Down syndrome; however, individuals with hydrocephalus may present with this finding. Polydactyly (choice D) is the presence of extra fingers or toes, which is not a typical feature of Down syndrome.