Nokea
A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include?
- A. Massaging reddened bony prominences
- B. Teaching the parents to turn the child every 4 hours
- C. Ensuring that nutritional intake meets requirements
- D. Minimizing use of extra linens, which can irritate the childs skin
Correct Answer: C
Rationale: Adequate nutrition prevents skin breakdown by supporting tissue health, especially in NPO children. Massaging bony prominences risks tissue damage, turning should occur every 2 hours by the nurse, and linens don?t typically cause irritation if managed properly.
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A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time?
- A. Allow her to wear her underpants.
- B. Discuss with her mother why this is important to the child.
- C. Ask her mother to explain to her why she cannot wear them.
- D. Explain in a kind, matter-of-fact manner that this is hospital policy.
Correct Answer: A
Rationale: Allowing the child to keep her underpants on provides a sense of control and comfort, and they can be removed later if needed for anesthesia. Discussing with the mother or citing hospital policy doesn?t address the child?s distress, and asking the mother to explain may escalate the situation.
A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate?
- A. Request these favorite foods for him.
- B. Identify healthier food choices that he likes.
- C. Explain that he needs fruits and vegetables.
- D. Reward him with ice cream at the end of every meal that he eats.
Correct Answer: A
Rationale: Requesting the child?s favorite foods encourages nutritional intake during illness, which can be supplemented with healthier options. Explaining nutritional needs or rewarding with ice cream is less effective, and focusing only on healthier foods may discourage eating.
A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do?
- A. Give him a large cup with ice so it tastes better.
- B. Restrict him to his room until he drinks the GoLYTELY.
- C. Use little cups and make a game to reward him for each cup he drinks.
- D. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.
Correct Answer: C
Rationale: Using small cups and making a game with rewards makes the large volume of GoLYTELY less daunting and encourages compliance. A large cup with ice increases the volume, restriction is punitive, and threats about the practitioner are ineffective and inappropriate.
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents?
- A. Febrile seizures can result.
- B. Antipyretics may cause malignant hyperthermia.
- C. Antipyretics are of no value in treating hyperthermia.
- D. Liver damage may occur in critically ill children.
Correct Answer: C
Rationale: Antipyretics are ineffective for hyperthermia, as the body?s temperature set point is normal, requiring cooling measures instead. Seizures are linked to fever, not hyperthermia; malignant hyperthermia is unrelated to antipyretics; and while liver damage is a risk with acetaminophen, it?s not the primary reason.
A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions?
- A. Droplet
- B. Contact
- C. Airborne
- D. Standard
Correct Answer: B
Rationale: MRSA is spread by direct contact, requiring contact precautions with gowns, gloves, and meticulous hand washing, in addition to a private room. Droplet and airborne precautions are for different pathogens, and standard precautions alone are insufficient.