Nokea
A child with a cardiac malformation associated with left-to-right shunting. What does this type of congenital disorder lead to primarily?
- 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: Left-to-right shunting in a cardiac malformation results in increased blood flow to the lungs. This increased blood flow can lead to pulmonary hypertension and heart failure if left untreated. Elevated hematocrit (Choice A) is not a characteristic directly associated with left-to-right shunting. Severe growth retardation (Choice B) is not a typical manifestation of this type of congenital disorder. Clubbing of the fingers and toes (Choice C) is more commonly seen in conditions like chronic respiratory or cardiac diseases, not specifically with left-to-right shunting and associated cardiac malformations.
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The nurse is caring for a boy with probable intussusception. He had diarrhea before admission, but while waiting for the administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate?
- A. notify the practitioner
- B. measure abdominal girth
- C. auscultate for bowel sounds
- D. take vital signs, including blood pressure
Correct Answer: A
Rationale: The passage of a normal brown stool in a child with intussusception could indicate spontaneous reduction of the intussusception. This change in the patient's condition is significant, requiring prompt notification of the practitioner for further evaluation and management. While measuring abdominal girth (Choice B) is important for assessing abdominal distention, it is not the priority when a potential spontaneous reduction may have occurred. Auscultating for bowel sounds (Choice C) and taking vital signs, including blood pressure (Choice D), are routine nursing assessments but do not address the immediate need to inform the practitioner of a possible change in the patient's condition that necessitates urgent attention.
What is the most common cause of shock (hypoperfusion) in infants and children?
- A. infection
- B. cardiac failure
- C. accidental poisoning
- D. severe allergic reaction
Correct Answer: A
Rationale: Infection is the most common cause of shock in infants and children due to their increased susceptibility to sepsis. Infants and children have underdeveloped immune systems, making them more prone to infections that can lead to septic shock. While cardiac failure is a serious condition, it is not the most common cause of shock in this population. Accidental poisoning, though dangerous, is less common than infection in causing shock in infants and children. Severe allergic reactions can lead to anaphylactic shock, but they are not as prevalent as infections in causing shock in this age group.
What is the priority intervention for a 10-year-old girl in a foster family?
- A. Determining if the child is being bullied at school
- B. Dealing with mixed parental expectations
- C. Establishing the child's primary caretaker
- D. Performing a comprehensive health assessment
Correct Answer: D
Rationale: In a foster family setup, the priority intervention for a 10-year-old girl is to perform a comprehensive health assessment. This is crucial as children in foster care may have moved between different homes, leading to incomplete medical records. A comprehensive health assessment helps identify any health issues, track the child's growth and development, and ensure appropriate medical care. While addressing bullying at school, managing parental expectations, and establishing the primary caretaker are important considerations, the immediate priority for the child's well-being and holistic care is to conduct a thorough health assessment.
The parent of a 2-year-old child is informed by the nurse that the toddler's negativism is expected at this age. What need is this behavior meeting?
- A. Trust
- B. Attention
- C. Discipline
- D. Independence
Correct Answer: D
Rationale: Negativism in toddlers commonly occurs around the age of 2 as they begin to assert their independence and autonomy. At this stage, children are exploring their own will and preferences, leading to behaviors like defiance or negativism. Independence (choice D) is the primary need being met by this behavior as toddlers strive to establish their individuality and decision-making. While trust (choice A) is crucial for forming secure attachments, it is not the main need driving negativism in this case. Seeking attention (choice B) may be a behavior exhibited by children, but it is not the fundamental need being fulfilled by negativism. Discipline (choice C) is important for setting boundaries and teaching appropriate conduct, but it is not the primary need being addressed by negativism in toddlers.
Parents of a sick infant talk with a nurse about their baby. One parent says, "I am so upset; I didn't realize our baby was ill." What major indication of illness in an infant should the nurse explain to the parent?
- A. Grunting respirations
- B. Excessive perspiration
- C. Longer periods of sleep
- D. Crying immediately after feedings
Correct Answer: C
Rationale: The correct answer is C. Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it can indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, not just an indication of illness. Excessive perspiration (choice B) can occur due to various reasons and is not a specific major indication of illness. Crying immediately after feedings (choice D) is a common behavior in infants and not necessarily a major indication of illness.