Nokea
A child is admitted with extensive burns. The nurse notes burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has a(n)
- A. chemical burn
- B. inhalation injury
- C. electrical burn
- D. hot-water scald
Correct Answer: B
Rationale: Burns on the lips and singed nasal hairs indicate inhalation injury, suggesting the child has inhaled hot gases or smoke. This presentation is common in cases where the respiratory tract is exposed to hot gases or smoke, leading to potential airway compromise. Choice A, chemical burn, is incorrect because there is no mention of exposure to chemicals, and the symptoms described are more indicative of inhalation injury. Choice C, electrical burn, is incorrect as there is no evidence of electrical involvement in the scenario provided. Choice D, hot-water scald, is incorrect because the presence of singed nasal hairs points more towards inhalation injury than a scald from hot water, emphasizing the need to prioritize airway management and respiratory support.
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What intervention best meets a major developmental need of a newborn in the immediate postoperative period?
- A. Giving a pacifier to the newborn
- B. Placing a mobile over the newborn's crib
- C. Providing the newborn with a soft, cuddly toy
- D. Warming the newborn's formula before feeding
Correct Answer: A
Rationale: The correct answer is giving a pacifier to the newborn. Sucking is a natural reflex and a source of comfort for newborns, especially postoperatively. Offering a pacifier can help meet their developmental needs by providing comfort and a soothing mechanism. Placing a mobile over the crib (choice B) may provide visual stimulation but does not directly address the newborn's developmental needs for comfort and self-soothing. Providing a soft, cuddly toy (choice C) may offer some comfort but may not be as effective in meeting the specific developmental need for sucking postoperatively. Warming the newborn's formula before feeding (choice D) relates more to feeding practices than directly addressing a major developmental need in the postoperative period.
What should be taught to the child and parents about using a peak flow meter for a child diagnosed with asthma?
- A. Use the device before taking medication
- B. Use the device during asthma attacks
- C. Record the best of three attempts
- D. Use the device after eating
Correct Answer: C
Rationale: The correct answer is to 'Record the best of three attempts.' This method provides an accurate measure of peak expiratory flow using a peak flow meter. By taking the best of three attempts, the child and parents can obtain a more reliable assessment of the child's lung function. Choices A, B, and D are incorrect because using the device before taking medication, during asthma attacks, or after eating does not ensure an accurate measurement of peak flow, which is essential for managing asthma effectively. Monitoring peak flow regularly and accurately can help in adjusting asthma treatment plans and assessing response to medications.
What is the priority nursing intervention for a child with a diagnosis of acute lymphoblastic leukemia (ALL) receiving chemotherapy?
- A. Preventing infection
- B. Administering chemotherapy
- C. Providing nutritional support
- D. Monitoring fluid intake
Correct Answer: A
Rationale: The correct answer is A: Preventing infection. When caring for a child with acute lymphoblastic leukemia (ALL) undergoing chemotherapy, the top priority is to prevent infection. Chemotherapy suppresses the immune system, making the child more susceptible to infections. By implementing infection control measures such as hand hygiene, aseptic techniques, and environmental cleanliness, the nurse can help protect the child from potentially life-threatening infections. Administering chemotherapy (choice B) is important but not the priority over preventing infection. Providing nutritional support (choice C) and monitoring fluid intake (choice D) are essential aspects of care but take a back seat to preventing infection in this scenario.
What factor predisposes the urinary tract to infection in children?
- A. increased fluid intake
- B. short urethra in young girls
- C. prostatic secretions in males
- D. frequent emptying of the bladder
Correct Answer: B
Rationale: The short urethra in young girls predisposes them to urinary tract infections. In young girls, the proximity of the urethra to the anus and the shorter urethra compared to boys make it easier for bacteria to travel up the urinary tract, increasing the risk of infection. Increased fluid intake and frequent emptying of the bladder are actually helpful in preventing urinary tract infections by flushing out bacteria. Prostatic secretions in males are not a factor in predisposing the urinary tract to infection in children.
Why does a cleft lip predispose an infant to infection?
- A. Waste products accumulate along the defect.
- B. There is evidence of inadequate circulation in the defective area.
- C. Nutrition is inadequate due to ineffective feeding.
- D. Mouth breathing dries the oropharyngeal mucous membranes.
Correct Answer: D
Rationale: The correct answer is D. Mouth breathing due to a cleft lip can dry the mucous membranes, making them more susceptible to infection. Choice A is incorrect because waste products do not accumulate along the defect to predispose the infant to infection. Choice B is incorrect as there is no evidence of inadequate circulation being a primary factor in infection predisposition in cleft lip cases. Choice C is incorrect because although ineffective feeding may lead to other issues, it is not the main reason for infection predisposition in infants with a cleft lip.