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A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Encourage a variety of large portions of food at every meal.
- B. Allow the child to eat any food desired and tolerated.
- C. Recommend eating the food as siblings eat at home.
- D. Restrict food brought from fast food restaurants.
Correct Answer: B
Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention for a child with altered nutrition due to anorexia, nausea, and vomiting. It is crucial to prioritize maintaining adequate nutritional intake, and by allowing the child to choose foods they desire and can tolerate, the chances of improving their nutritional status increase. This approach helps in ensuring that the child receives necessary nutrients during chemotherapy, even if their appetite is affected by the treatment.
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A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol (Proventil). The child's mother tells the nurse that she uses this medication to open her son's airway when he is having trouble breathing. What is the nurse's best response?
- A. Recommend that the mother bring the child in for immediate evaluation
- B. Advise the mother that overuse of the drug may cause chronic bronchitis
- C. Assure the mother that she is using the medication correctly
- D. Confirm that the medication helps to reduce airway inflammation
Correct Answer: C
Rationale: The correct response is to assure the mother that she is using the medication correctly. Albuterol is a beta-adrenergic agonist that helps open the airways during an asthma attack. By reassuring the mother, the nurse reinforces the correct usage of the medication, which is crucial in managing the child's asthma symptoms effectively.
The infant scheduled for reduction of intussusception passes a soft-formed brown stool the day before the scheduled procedure. Which intervention should the nurse implement?
- A. Instruct the parents that the infant needs to be NPO.
- B. Notify the healthcare provider of the passage of brown stool.
- C. Obtain a stool specimen for laboratory analysis.
- D. Ask the parents about recent changes in the infant's diet.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?
- A. Describe the side-lying, knees to chest position that must be assumed during the procedure.
- B. Tell the child to expect loud clicking noises during the procedure that may be slightly annoying.
- C. Reassure the child that there will be no restrictions on activity after the procedure is completed.
- D. Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 7-year-old child with type 1 diabetes is brought to the emergency department with abdominal pain, nausea, and vomiting. The nurse notes that the child's blood glucose level is 350 mg/dL. What should the nurse do first?
- A. Administer IV fluids as prescribed
- B. Administer insulin as prescribed
- C. Monitor the child's urine output
- D. Check the child's urine for ketones
Correct Answer: A
Rationale: In a child with type 1 diabetes presenting with abdominal pain, nausea, vomiting, and a high blood glucose level, the priority is to administer IV fluids to correct dehydration and electrolyte imbalances, which are crucial in managing diabetic ketoacidosis. Administering insulin without addressing fluid deficits can lead to further complications. Monitoring urine output and checking for ketones are important steps but providing IV fluids takes precedence in the initial management of this child's condition.
The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
- A. Turn the infant on the left side braced against the crib when sleeping.
- B. Prop the infant in a sitting position with a cushion when not sleeping.
- C. Place a small pillow under the infant's head while lying on the back.
- D. Position the infant on the stomach occasionally when awake and active.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.