Nokea
A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?
- A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
- B. Risk for aspiration related to feeding the infant an inappropriate food
- C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
- D. Readiness for enhanced nutrition, related to the age of the infant
Correct Answer: B
Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.
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A breastfed infant is being seen in the clinic for a 6-month checkup. The mother tells the nurse that the infant recently began to suck her thumb. Which is the best nursing intervention?
- A. Reassure the mother that this is normal at this age
- B. Recommend the mother substitute a pacifier for her thumb
- C. Assess the infant for other signs of sensory deprivation
- D. Suggest the mother breastfeed the infant more often to satisfy her sucking needs
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In planning care for children, the nurse considers children's anxiety about hospitalization. Which measure should be included in the child's plan of care to help reduce anxiety?
- A. Therapeutic play
- B. Time-out
- C. Counseling
- D. Movies
Correct Answer: A
Rationale: Therapeutic play should be included in the child's plan of care to help reduce anxiety during hospitalization. It is an effective strategy that allows children to express their feelings, understand procedures, and reduce anxiety levels. Time-out (choice B) is not suitable for addressing anxiety related to hospitalization. Counseling (choice C) may be beneficial but is not as specifically tailored to reduce anxiety in the hospital setting as therapeutic play. Movies (choice D) may provide a temporary distraction but do not actively involve the child in addressing their emotions and fears associated with hospitalization.
Which medication should the nurse expect to administer to a child with an acute sickle cell pain crisis?
- A. Meperidine (Demerol)
- B. Morphine
- C. Acetaminophen (Tylenol)
- D. Ibuprofen (Motrin)
Correct Answer: B
Rationale: In the management of acute sickle cell pain crisis in children, morphine is the preferred medication due to its effectiveness in providing pain relief. Meperidine (Demerol) is less commonly used in this scenario because of its potential for neurotoxicity with repeated doses. Acetaminophen (Tylenol) and Ibuprofen (Motrin) are not typically sufficient for managing the severe pain associated with sickle cell crises and are not the first-line treatment options.
An intravenous line is needed in a school-age child. What medication is an appropriate analgesic for use with this patient?
- A. TAC (tetracaine, epinephrine [Adrenalin], cocaine) 15 minutes before the procedure.
- B. A transdermal fentanyl (Duragesic) patch at the site of venipuncture.
- C. EMLA (eutectic mixture of local anesthetics) immediately before the procedure.
- D. LMX (4% liposomal lidocaine cream) 30 minutes before the procedure.
Correct Answer: D
Rationale: LMX is an effective analgesic agent when applied to the skin 30 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin, making it more suitable for wound suturing. Transdermal fentanyl patches are designed for continuous pain control, not rapid pain control needed for a procedure like venipuncture. EMLA, for maximum effectiveness, must be applied approximately 60 minutes before the procedure, making it less suitable for immediate pain relief required for intravenous line placement.
The parents of a 12-month-old child ask the nurse if the child can eat hot dogs as do their other children. The nurse's reply should be based on what?
- A. The child is too young to digest hot dogs.
- B. The child is too young to eat hot dogs safely.
- C. Hot dogs must be sliced into sections to prevent aspiration.
- D. Hot dogs must be cut into small, irregular pieces to prevent aspiration.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.