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A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
- A. Permanent lifestyle changes need to be made to promote safety in the home
- B. The chorea or movements are temporary and will eventually disappear
- C. Muscle tension is decreased with fine motor project skills, so these activities should be encouraged
- D. Consistent discipline is needed to help the child control the movements
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is caring for a 3-year-old child who has been recently diagnosed with cystic fibrosis. Which discharge instruction by the nurse is most important to promote pulmonary function?
- A. Chest physiotherapy should be performed before meals and at bedtime
- B. Cough suppressants can be used up to four times a day for relief
- C. Oxygen should be given through a nasal cannula between 4-6 L/min
- D. Exercise is discouraged in order to preserve pulmonary vital capacity
Correct Answer: B
Rationale: In cystic fibrosis, thick mucus obstructs the airways, making it difficult to clear from the lungs. Cough suppressants can help reduce the discomfort associated with persistent coughing, allowing the child to cough more effectively to clear the mucus, thus promoting pulmonary function. Chest physiotherapy, not exercise, helps mobilize the mucus. Oxygen therapy may be needed but is not the most important for promoting pulmonary function in this case.
A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?
- A. The mother is a single parent and lives with her parents
- B. The mother states the baby is irritable during feedings
- C. The infant's formula has been changed twice
- D. The diaper area shows severe skin breakdown
Correct Answer: D
Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.
A 3-year-old child with a high fever and sore throat is brought to the clinic. The nurse observes that the child is drooling and has difficulty swallowing. What is the nurse's priority action?
- A. Administer antipyretic medication
- B. Prepare for emergency airway management
- C. Offer the child ice chips to suck on
- D. Assess the child's hydration status
Correct Answer: B
Rationale: In a 3-year-old child with drooling, difficulty swallowing, high fever, and sore throat, the nurse should prioritize preparing for emergency airway management. These signs may indicate epiglottitis, a condition that can quickly obstruct the airway, leading to respiratory distress and potentially fatal outcomes if not managed promptly. Administering antipyretic medication (Choice A) may be necessary later but is not the priority. Offering ice chips (Choice C) is contraindicated as the child has difficulty swallowing. Assessing hydration status (Choice D) is important but not the priority when the airway is at risk.
A 4-year-old child with a history of asthma is brought to the clinic with a complaint of cough and wheezing. The nurse notes that the child has been using a rescue inhaler more frequently over the past week. What should the nurse do next?
- A. Review the child's asthma action plan
- B. Administer a dose of the rescue inhaler
- C. Instruct the parents to increase the dose of the controller medication
- D. Schedule a follow-up appointment in one week
Correct Answer: A
Rationale: In this scenario, the best course of action for the nurse is to review the child's asthma action plan. By doing so, the nurse can assess the current asthma management, ensure that the child is using the rescue inhaler correctly, and make any necessary adjustments to the treatment plan. Reviewing the asthma action plan helps in identifying triggers, proper use of medications, and when to seek medical help. Administering a dose of the rescue inhaler without assessing the current management plan may not address the underlying issue. Instructing the parents to increase the dose of the controller medication without proper evaluation can lead to inappropriate medication adjustments. Scheduling a follow-up appointment in one week is not the immediate action needed to address the child's current symptoms.
The mother of a 9-month-old, diagnosed with respiratory syncytial virus (RSV) yesterday, calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day. What response should the nurse provide this mother?
- A. The child will no longer be contagious, so no need to take any further precautions.
- B. Ensure there are no children under the age of 6 months around the infected child.
- C. The child can be around other children but should wear a mask at all times.
- D. Do not expose other children to RSV. It is highly contagious even without direct contact.
Correct Answer: D
Rationale: The correct answer is D. RSV is highly contagious, even without direct contact. It is important to prevent the spread of the virus to other children, so the infected child should not attend the birthday party to avoid exposing other children to RSV. This is crucial to protect the health of other children who may be more vulnerable to the virus. Choices A, B, and C are incorrect. Choice A is incorrect as RSV remains contagious for a period of time, and precautions should be taken to prevent its spread. Choice B is incorrect because the age limit specified is not a reliable measure to prevent transmission. Choice C is incorrect as wearing a mask may not be sufficient to prevent the spread of RSV in a social setting like a birthday party.