Nokea
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct response is A: Your baby needs an IV because she is not producing tears. In infants, the inability to produce tears is a sign of severe dehydration, indicating a deficit in body fluids. Tears are composed of water and electrolytes, and the absence of tears suggests a significant fluid imbalance. This makes it crucial to administer parenteral fluid therapy via an IV to restore hydration levels.
Choices B, C, and D are incorrect because they do not directly correlate with the need for IV fluid therapy in this scenario. A decreased heart rate, slower breathing, and bulging fontanels may be signs of distress or other issues but do not specifically indicate the need for immediate IV fluid administration due to dehydration. Therefore, option A is the most appropriate and relevant response given the infant's presentation of severe dehydration.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Provide the client, with foods that have a variety of textures, Accept the client’s belief about "forbidden" foods, Focus on the client’s underlying feelings of lack of control, Encourage the client to limit fasting, Provide a structured meal environment.
- B. Bulimia Nervosa, Binge eating disorder, Anorexia nervosa, Avoidant/restrictive food intake disorder.
- C. Cardiac function with ECG, Weight on a daily basis, Calcium level, Vital signs every 8 hr, Behavior 15min after meals.
Correct Answer: A[2,4],B[2],C[0,4]
Rationale: Action to Take: Provide the client with foods that have a variety of textures, Encourage the client to limit fasting; Potential Condition: Anorexia nervosa; Parameter to Monitor: Weight on a daily basis, Behavior 15 minutes after meals.
Rationale: In anorexia nervosa, the client typically has a fear of gaining weight, leading to restrictive eating habits. Providing foods with different textures can help normalize eating habits and improve nutrition. Encouraging the client to limit fasting can help address the underlying issue of restricted food intake. Weight monitoring is crucial in assessing nutritional status, while monitoring behavior post-meals can provide insights into the client's relationship with food. Bulimia nervosa and binge eating disorder are not the most likely conditions based on the client's symptoms. Monitoring cardiac function with ECG and calcium level are not the primary parameters for assessing progress in anorexia nervosa.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room
- B. Administer aspirin to the child for fever
- C. Use droplet precautions when caring for the child
- D. Assess the child for health spots
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella (chickenpox) is highly contagious and spreads through airborne particles. Placing the child in a negative air pressure room helps prevent the spread of the virus to other patients and staff. Administering aspirin to a child with varicella can lead to Reye's syndrome, making choice B incorrect. Droplet precautions are used for illnesses like influenza or pertussis, not varicella, so choice C is incorrect. Choice D is incorrect because the characteristic rash in varicella is not described as health spots.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the epiglottis becomes inflamed and can lead to airway obstruction. Intubation may be necessary to secure the airway and ensure the child can breathe. It is a priority action to maintain the child's oxygenation and ventilation. Obtaining a throat culture (B) can be important for diagnosis but is not the immediate priority. Suctioning the child's oropharynx (C) can trigger a spasm and worsen the obstruction. Cool mist tent (D) is not indicated in the management of epiglottitis.
The nurse is continuing to care for the child. The nurse should anticipate a prescription for pain medication.
- A. Skin traction
- B. Surgical consultation
- C. Antibiotics
- D. Pain medication
- E. Limb immobilization
- F. Bed rest
Correct Answer: B,D
Rationale: The correct answers are B and D. A surgical consultation (B) may be needed to address the underlying cause of the child's pain. Pain medication (D) is essential to provide comfort and manage the child's pain. Skin traction (A) and limb immobilization (E) are interventions for orthopedic issues, not for immediate pain relief. Antibiotics (C) are not indicated unless there is an infection. Bed rest (F) is not a proactive measure for pain management.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.