Nokea
A 6-year-old child with asthma is admitted to the hospital with an acute exacerbation. What is the priority nursing intervention?
- A. Administering a bronchodilator
- B. Administering an antihistamine
- C. Administering a corticosteroid
- D. Administering oxygen
Correct Answer: A
Rationale: Administering a bronchodilator is the priority intervention for a child experiencing an acute asthma exacerbation. Bronchodilators help to dilate the airways quickly, providing immediate relief by opening up the narrowed air passages in asthma. Antihistamines are not the first-line treatment for asthma exacerbations and may not address the underlying bronchoconstriction. Corticosteroids are important for long-term control of asthma but may take longer to have an effect compared to bronchodilators. Administering oxygen is essential for hypoxemia in asthma exacerbations, but the priority is to relieve bronchoconstriction promptly with a bronchodilator.
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A nurse is teaching the parents of a child with a diagnosis of epilepsy about seizure precautions. What should the nurse include in the teaching?
- A. Keep a diary of seizure activity
- B. Administer antiepileptic medication only when a seizure occurs
- C. Restrict the child's activities to prevent seizures
- D. Teach seizure first aid to family members
Correct Answer: D
Rationale: Teaching seizure first aid to family members is essential as it empowers them to respond effectively during a seizure. Keeping a diary of seizure activity is important for tracking patterns and triggers but is not directly related to immediate safety. Administering antiepileptic medication only when a seizure occurs is not recommended as medications should be administered as prescribed by healthcare providers. Restricting the child's activities to prevent seizures is not appropriate as children with epilepsy should be encouraged to lead active lives while taking necessary precautions.
After a cardiac catheterization, what is the priority nursing care for a 3-year-old child?
- A. Encouraging early ambulation
- B. Monitoring the site for bleeding
- C. Restricting fluids until the blood pressure is stabilized
- D. Comparing the blood pressure of both lower extremities
Correct Answer: B
Rationale: After a cardiac catheterization, the priority nursing care for a 3-year-old child is monitoring the site for bleeding. This is essential to promptly identify and address any signs of bleeding or hematoma formation, which are potential complications of the procedure. Encouraging early ambulation may be beneficial post-procedure but ensuring site integrity takes precedence. Restricting fluids until blood pressure stabilization is not a standard post-catheterization practice, as adequate hydration is crucial for recovery. Comparing the blood pressure of both lower extremities is not a priority immediate nursing action after a cardiac catheterization in a pediatric patient.
At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. The woman states that her contractions are occurring every 4 to 5 minutes and lasting approximately 30 seconds each. Which of the following questions would be most appropriate to ask at this point?
- A. Has your bag of waters broken yet?
- B. Have you had regular prenatal care?
- C. At how many weeks gestation are you?
- D. How many other children do you have?
Correct Answer: C
Rationale: Asking about the gestational age is crucial in determining the stage of labor and assessing potential complications. This information helps in understanding the progress of labor and making appropriate decisions regarding the management of the delivery process. Choices A, B, and D are not as pertinent at this point in providing immediate care or assessing the situation compared to knowing the gestational age.
A healthcare professional is assessing a child with suspected bacterial meningitis. What is a common clinical manifestation that the healthcare professional is likely to observe?
- A. Rash
- B. Photophobia
- C. Jaundice
- D. Kernig sign
Correct Answer: D
Rationale: A common clinical manifestation of bacterial meningitis is a positive Kernig sign, indicating irritation of the meninges. Rash (Choice A) is not typically associated with bacterial meningitis. Photophobia (Choice B) can be present but is more commonly seen in viral meningitis. Jaundice (Choice C) is not a typical clinical manifestation of meningitis and is more indicative of liver dysfunction.
A nurse is assessing a 10-month-old infant. What developmental milestone should the nurse expect to observe?
- A. Crawling
- B. Sitting without support
- C. Standing with assistance
- D. Pulling to a stand
Correct Answer: D
Rationale: The correct answer is D: Pulling to a stand. By 10 months of age, most infants should be able to pull themselves up to a standing position while holding onto furniture or other support. This milestone indicates good strength and coordination in the lower body. Choice A, Crawling, is typically achieved around 6-9 months of age. Choice B, Sitting without support, usually occurs around 6-8 months. Choice C, Standing with assistance, can typically be seen around 9-12 months, but pulling to a stand is a more advanced milestone expected by 10 months.