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A 9-year-old child who has acute rheumatic fever
A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?
- A. Has your son had a sore throat recently?
- B. Was your son born with this cardiac defect?
- C. Are you aware that your son will have to be in isolation?
- D. Has your child had any injuries recently?
Correct Answer: A
Rationale: Rationale: A sore throat can be a symptom of acute rheumatic fever, which is important for the nurse to assess. This can help in diagnosing the condition and planning appropriate care. Asking about a recent sore throat is relevant to the child's current health status and can guide further assessment and treatment.
Summary:
B: This question is not relevant to acute rheumatic fever.
C: Isolation is not necessary for acute rheumatic fever, so this question is not appropriate.
D: Recent injuries are not directly related to acute rheumatic fever and are not relevant to the child's current condition.
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An adolescent who is having a sickle cell crisis
A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
- A. withhold opioids to avoid dependence
- B. Assist RN with administering a blood transfusion
- C. Initiate a 2 L/day fluid restriction
- D. Encourage exercise
Correct Answer: B
Rationale: The correct answer is B: Assist RN with administering a blood transfusion. During a sickle cell crisis, blood transfusions can help improve oxygen delivery to tissues by increasing the number of normal red blood cells. This can help alleviate symptoms and prevent complications. Withholding opioids (choice A) can lead to inadequate pain management. Initiation of fluid restriction (choice C) is inappropriate as hydration is crucial during a sickle cell crisis. Encouraging exercise (choice D) can worsen the crisis by increasing the risk of vaso-occlusive events.
An infant who has coarctation of the aorta
A nurse is collecting data from an infant who has coarctation of the aorta. Which of the following manifestations should the nurse expect?
- A. Machine-like murmur
- B. Severe cyanosis
- C. Decreased blood pressure in the legs
- D. Pulmonary edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to decreased blood flow to the lower body. This results in decreased blood pressure in the legs due to reduced perfusion. A machine-like murmur (A) is typically associated with patent ductus arteriosus. Severe cyanosis (B) is more commonly seen in conditions like Tetralogy of Fallot. Pulmonary edema (D) is often seen in congestive heart failure.
A 14-month-old toddler who is 24 hr following interventions
A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 h following interventions should the nurse include in the plan?
- A. Give the toddler a hard-tipped sippy cup to drink liquid
- B. Suction the toddler nose and mouth every hour
- C. Maintain elbow restraint
- D. Provide soft foods for the toddler
Correct Answer: D
Rationale: The correct answer is D: Provide soft foods for the toddler. At 14 months, toddlers should be transitioning to a diet of soft foods to aid in their development and prevent choking hazards. Hard-tipped sippy cups (choice A) are not recommended as they can pose a risk of injury. Suctioning the toddler's nose and mouth every hour (choice B) is excessive and can lead to irritation and discomfort. Maintaining elbow restraint (choice C) is unnecessary and may hinder the toddler's mobility and development. In summary, providing soft foods aligns with the toddler's age and promotes safe and appropriate feeding practices.
An infant who has respiratory syncytial virus (RSV)
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV), which of the following rooms should the nurse assign the infant?
- A. A room with a toddler who has pneumonia
- B. A private room with reverse isolation
- C. A private room with contact/droplet precautions
- D. A room with an infant who has croup
Correct Answer: C
Rationale: The correct answer is C: A private room with contact/droplet precautions. RSV is spread through respiratory secretions, so contact/droplet precautions are necessary to prevent transmission. Assigning the infant to a private room minimizes exposure to others. Choice A is incorrect as it puts the infant at risk of acquiring pneumonia. Choice B, reverse isolation, is not needed for RSV. Choice D, room with an infant with croup, is incorrect as both infants could potentially spread their respective infections to each other.
A 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt
A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority?
- A. Lethargy
- B. Urine output 70 mL in 2 hr
- C. Lying flat on the unaffected side
- D. Respiratory rate 20/min
Correct Answer: A
Rationale: The correct answer is A: Lethargy. Following a ventriculoperitoneal shunt insertion, lethargy in a child could indicate increased intracranial pressure, a potentially life-threatening complication. The priority is to assess for signs of neurological deterioration promptly. Urine output (B) is important but not as urgent as assessing neurological status. Lying flat on the unaffected side (C) is not a priority; positioning can be adjusted later. Respiratory rate (D) within normal range is reassuring but not the priority in this case.