Nokea
A child with a cardiac malformation associated with left-to-right shunting is being cared for by a nurse. What does the nurse consider to be the major characteristic of this type of congenital disorder?
- A. Elevated hematocrit
- B. Severe growth retardation
- C. Clubbing of the fingers and toes
- D. Increased blood flow to the lungs
Correct Answer: D
Rationale: The major characteristic of a cardiac malformation associated with left-to-right shunting is increased blood flow to the lungs. This increased flow can lead to pulmonary hypertension and heart failure if left untreated. Elevated hematocrit (Choice A) is not a typical characteristic of this condition. Severe growth retardation (Choice B) is not directly associated with left-to-right shunting. Clubbing of the fingers and toes (Choice C) is more commonly seen in conditions involving chronic hypoxia.
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A child is being assessed for suspected intussusception. What clinical manifestation is the healthcare provider likely to observe?
- A. Projectile vomiting
- B. Currant jelly stools
- C. Abdominal distension
- D. Constipation
Correct Answer: C
Rationale: The correct clinical manifestation the healthcare provider is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception involves one portion of the intestine telescoping into another, causing obstruction. Abdominal distension is a common symptom due to the obstruction and buildup of gas and fluid in the affected area. While projectile vomiting can occur, it is not as specific to intussusception as abdominal distension. Currant jelly stools, which are stools containing blood and mucus, are a classic sign of intussusception but are not a clinical manifestation observable on assessment. Constipation is not typically associated with intussusception, as this condition often presents with symptoms of bowel obstruction rather than constipation.
A nurse is teaching the parents of a toddler about the signs and symptoms of lead poisoning. Which symptom should the nurse emphasize?
- A. Abdominal pain
- B. Constipation
- C. Irritability
- D. Frequent urination
Correct Answer: C
Rationale: Irritability is a significant symptom of lead poisoning in toddlers and should be emphasized to parents. Lead poisoning can manifest with various symptoms, but irritability is particularly common in children exposed to lead. Abdominal pain (Choice A) is not a typical symptom of lead poisoning in toddlers. While constipation (Choice B) can occur, it is less specific and less common than irritability. Frequent urination (Choice D) is not a typical symptom associated with lead poisoning in toddlers and is less relevant for parents to recognize in this context.
A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?
- A. "Tell me about your daily routine."
- B. "You look tired. Is everything alright?"
- C. "When was the last time the baby had a bottle?"
- D. "Oh, it looks like you two are having a bad day."
Correct Answer: A
Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.
When caring for a 2-year-old girl who is wheezing and has difficulty breathing, which interview question would provide the most useful information related to the symptoms of the child?
- A. Inquiring about child safety in the home
- B. Asking about the temperament of the child
- C. Asking about the child's diet
- D. Asking the parents if they smoke in the home
Correct Answer: D
Rationale: Asking the parents if they smoke in the home is the most relevant question as exposure to secondhand smoke can exacerbate respiratory symptoms like wheezing and difficulty breathing in children. Smoking indoors can worsen the child's condition and is crucial information for the healthcare provider to assess and address. Inquiring about child safety in the home, asking about the child's temperament, and questioning the child's diet are important aspects of care but are not directly linked to the immediate respiratory symptoms the child is experiencing.
A child is brought to the clinic after tripping over a rock. The child states, 'I twisted my ankle,' and is given a diagnosis of a sprain. What intervention is most important for the nurse to include in the discharge instructions for this child?
- A. For the first 24 hours, apply ice for 20 minutes and remove for 60 minutes.
- B. Bed rest with the leg elevated for 36 hours.
- C. May take an NSAID for pain as prescribed.
- D. Use a compression dressing for 72 hours.
Correct Answer: A
Rationale: The correct answer is A. Applying ice in intervals helps to reduce swelling and pain in the first 24 hours after a sprain. This intervention is crucial in the initial management of a sprain to decrease inflammation and provide pain relief. Bed rest with the leg elevated for 36 hours (Choice B) is not recommended as prolonged immobilization can lead to stiffness and decreased range of motion. Allowing the child to take an NSAID for pain as prescribed (Choice C) is a supportive measure but not as essential as ice application in the acute phase. Using a compression dressing for 72 hours (Choice D) may assist in reducing swelling, but it is not as critical as the immediate application of ice to manage pain and inflammation effectively.