Nokea
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which of the following nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply.
- A. Offer an ice pack.
- B. Apply a heating pad.
- C. Encourage the child to assume a position of comfort.
- D. Limit the child's activity.
- E. Request an order for a cathartic.
Correct Answer: A,C,D
Rationale: Ice, comfortable positioning, and activity limitation reduce pain; heating pads and cathartics may worsen appendicitis.
You may also like to solve these questions
Which of the following instructions should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy?
- A. Change diapers as soon as they become soiled.
- B. Apply an abdominal binder.
- C. Keep the incision covered with a sterile dressing.
- D. Restrain the infant's hands.
Correct Answer: A
Rationale: Prompt diaper changes prevent irritation and infection at the surgical site.
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse's best response?
- A. Newborns cry and cannot be distracted to stop crying.
- B. When faced with a pain, newborns try to roll away from it.
- C. Newborns typically move their whole body in response to pain.
- D. Pain causes the newborn to withdraw the affected part.
Correct Answer: C
Rationale: Newborns exhibit a generalized body response to pain, such as squirming or thrashing.
What should be part of the nurse's teaching plan for a child with epilepsy being discharged on a regimen of diphenylhydantoin (Dilantin)?
- A. Drinking plenty of fluids.
- B. Brushing teeth after each meal.
- C. Having someone be with the child during waking hours.
- D. Reporting signs of infection.
Correct Answer: B
Rationale: Dilantin can cause gingival hyperplasia; brushing after meals promotes oral hygiene to mitigate this side effect.
During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which of the following findings should lead the nurse to formulate the nursing diagnosis Risk for infection?
- A. Dialysate leakage.
- B. Granulation tissue.
- C. Increased time for drainage.
- D. Tissue swelling.
Correct Answer: A
Rationale: Leakage increases infection risk.
After insertion of bilateral tympanostomy tubes in a toddler, which of the following instructions should the nurse include in the child's discharge plan for the parents?
- A. Insert ear plugs into the canals when the child bathes.
- B. Blow the nose forcibly during a cold.
- C. Administer the prescribed antibiotic while the tubes are in place.
- D. Disregard any drainage from the ear after 1 week.
Correct Answer: C
Rationale: Administering prescribed antibiotics as directed is crucial to prevent infection after tympanostomy tube insertion. Ear plugs are not typically recommended, as they can introduce bacteria. Forcibly blowing the nose can disrupt the tubes, and any drainage after 1 week should be reported, not disregarded.