Nokea
A healthcare provider is assessing a child with suspected bacterial meningitis. What clinical manifestation is the healthcare provider likely to observe?
- A. Photophobia
- B. High fever
- C. Rash
- D. Nasal congestion
Correct Answer: B
Rationale: High fever is a key clinical manifestation of bacterial meningitis due to the inflammatory response in the meninges. Photophobia, choice A, is also commonly observed due to meningeal irritation, but it is not as specific as high fever. Rash, choice C, is more indicative of conditions like meningococcal meningitis rather than bacterial meningitis. Nasal congestion, choice D, is not typically associated with bacterial meningitis. Therefore, the correct answer is B.
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A 13-year-old girl tells the nurse at the pediatric clinic that she took a pregnancy test and it was positive. She adds that her grandfather, with whom she, her younger sisters, and her mother live, has repeatedly molested her for the past 3 years. When the nurse asks the girl if she has told this to anyone, she replies, 'Yes, but my mother doesn't believe me.' Legally, who should the nurse notify?
- A. Police regarding a potential sex crime
- B. Health care provider to confirm the pregnancy
- C. Child Protective Services for immediate intervention
- D. The girl's mother about the positive pregnancy test result
Correct Answer: C
Rationale: In cases of child abuse and ongoing molestation, as described in the scenario, the primary concern is the safety and well-being of the child. Child Protective Services should be notified immediately for intervention to protect the girl and other children in the household from further harm. The police may be involved later to investigate the criminal aspect of the abuse. Notifying the healthcare provider solely to confirm the pregnancy or informing the girl's mother about the positive test result does not address the urgent need for intervention and protection from abuse. Child Protective Services are trained to handle such cases and provide the necessary support and protection for the child and other vulnerable individuals in the family. Immediate action is crucial to ensure the girl's safety and prevent further harm.
Your assessment of a mother in active labor reveals that a limb is protruding from the vagina. Management of this condition should include:
- A. Positioning the mother in a semi-Fowler's position, administering oxygen, and providing transport
- B. Positioning the mother in a head-down position with her hips elevated, administering oxygen, and providing transport
- C. Applying gentle traction to the protruding limb to remove pressure of the fetus from the umbilical cord
- D. Giving the mother 100% oxygen and attempting to manipulate the protruding limb so that delivery can occur
Correct Answer: B
Rationale: In a situation where a limb is protruding from the vagina during active labor, the correct management includes positioning the mother in a head-down position with her hips elevated. This position helps relieve pressure on the umbilical cord and improves oxygenation to the fetus. Administering oxygen is important to ensure adequate oxygen supply to both the mother and the baby. Providing transport is necessary for prompt transfer to a medical facility for further management. Applying gentle traction to the protruding limb is not recommended as it can cause harm to the baby and should be avoided. Giving 100% oxygen and attempting to manipulate the protruding limb is not the correct approach and can potentially lead to further complications.
While waiting for the administration of air pressure to reduce the intussusception, the boy passes a normal brown stool. Which nursing action is the most appropriate for the nurse to take?
- 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 correct answer is to notify the practitioner. The passage of a normal brown stool in a child with intussusception could indicate spontaneous reduction of the intussusception. It is crucial to inform the practitioner immediately so that they can reassess the situation and determine the next steps, which may include adjusting the planned intervention. Measuring abdominal girth (choice B) may be important in assessing for abdominal distension but is not the most immediate action required in this scenario. Auscultating for bowel sounds (choice C) is a routine nursing assessment but does not take precedence over notifying the practitioner in this critical situation. Taking vital signs, including blood pressure (choice D), is also important but notifying the practitioner is more urgent to address the unexpected change in the patient's condition.
A parent tells the nurse in the emergency department, 'My 3-year-old has had a fever for several days and has been vomiting.' After instituting ordered measures to reduce the fever, what nursing action is most important?
- A. Preventing shivering
- B. Restricting oral fluids
- C. Measuring output hourly
- D. Taking vital signs hourly
Correct Answer: A
Rationale: Preventing shivering is crucial in this scenario as it can increase body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat through muscle activity, which can elevate the body temperature. Restricting oral fluids (choice B) is inappropriate as maintaining hydration is vital, especially in cases of fever and vomiting. Measuring output hourly (choice C) and taking vital signs hourly (choice D) are important nursing actions but not the most critical in this case where preventing shivering takes precedence.
What is the typical therapeutic management treatment for children with Hirschsprung disease?
- A. Daily enemas
- B. Low-fiber diet
- C. Permanent colostomy
- D. Surgical removal of affected section of bowel
Correct Answer: D
Rationale: The most common treatment for Hirschsprung disease is the surgical removal of the affected section of the bowel. This procedure entails excising the part of the colon that lacks nerve cells crucial for normal bowel function. Daily enemas (Choice A) can offer temporary relief for constipation but do not address the root cause of the condition, which is the absence of nerve cells. A low-fiber diet (Choice B) is not a primary therapy for Hirschsprung disease and may not effectively manage the disorder. A permanent colostomy (Choice C) is typically considered in severe cases where other interventions have failed and is not the standard management approach for Hirschsprung disease.