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A nurse is caring for a 4-year-old child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make?
- A. I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me.
- B. Children who are hospitalized often regress. The toileting skills will return when your child is feeling better.
- C. I will discuss your child's loss of bladder control with the provider.
- D. Why is she wetting the bed in the hospital? She must wet the bed at home.
Correct Answer: B
Rationale: I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me.' This response acknowledges the child's feelings and reassures the parents that bedwetting is a common occurrence, especially during hospitalization. It also demonstrates empathy by sharing a personal experience. However, it may not address the parents' concerns about their child's bedwetting or provide information on how to manage it. 'Children who are hospitalized often regress. The toileting skills will return when your child is feeling better.' This response provides an explanation for the bedwetting incident, reassuring the parents that it is a common response to hospitalization and will likely resolve once the child feels better. It offers support and normalization of the behavior, which can help alleviate the parents' concerns. 'I will discuss your child's loss of bladder control with the provider.' This response indicates that the nurse will address the issue with the healthcare provider, which is appropriate if further evaluation or intervention is needed. However, it may not directly address the parents' concerns or provide immediate reassurance. 'Why is she wetting the bed in the hospital? She must wet the bed at home.' This response may come across as accusatory or judgmental, which can increase parental anxiety or guilt. It does not provide reassurance or support to the parents and does not address the child's immediate needs.
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The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?
- A. “There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance.
- B. I will have my child wear an eye patch over the good eye to help strengthen the weak eye.
- C. My child will outgrow this by the time he is 2 years old and be able to see just fine.
- D. If this eye patch does not work I know we will have to do surgery to correct my child's crossed eyes.
Correct Answer: C
Rationale: There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance.': This statement demonstrates the mother's comprehension of the cause of strabismus, which can indeed result from a muscle imbalance affecting the alignment of the eyes. Understanding the cause is essential for the mother to grasp the rationale behind treatment interventions. 'I will have my child wear an eye patch over the good eye to help strengthen the weak eye.': Patching the stronger eye is a common treatment approach for strabismus to encourage the weaker eye to become stronger and improve alignment. The mother's statement indicates her awareness of this treatment modality. 'My child will outgrow this by the time he is 2 years old and be able to see just fine.': While some cases of strabismus may improve as a child grows, not all cases resolve spontaneously. This statement suggests the mother's belief in the possibility of spontaneous resolution, which may be accurate in some instances but not guaranteed for all cases of strabismus. 'If this eye patch does not work I know we will have to do surgery to correct my child's crossed eyes.': Surgery is indeed an option for correcting strabismus, especially if conservative measures like patching do not yield satisfactory results. The mother's understanding of this potential treatment escalation reflects her grasp of the condition's management plan.
A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will have to feed my baby formula, rather than breast milk.
- B. I should move my baby into a side-lying position during sleep.
- C. My baby's formula can be thickened with oatmeal.
- D. I will keep my baby in an upright position after feedings.
Correct Answer: D
Rationale: I will have to feed my baby formula, rather than breast milk.' - This statement indicates a misunderstanding. Breast milk is generally preferred for infants with gastroesophageal reflux (GER) because it is more easily digested and less likely to exacerbate reflux symptoms compared to formula. Breastfeeding mothers may be encouraged to continue breastfeeding, and formula-fed infants may benefit from specialized formulas designed to reduce reflux symptoms. 'I should move my baby into a side-lying position during sleep.' - This statement indicates a misunderstanding. Placing an infant in a side-lying position during sleep is not recommended due to the risk of sudden infant death syndrome (SIDS). Instead, infants with GER should be placed on their back to sleep, as recommended by safe sleep guidelines. Elevating the head of the crib or bassinet slightly may also help reduce reflux symptoms during sleep. 'My baby's formula can be thickened with oatmeal.' - This statement indicates an understanding of the teaching. Thickening formula with oatmeal or rice cereal can help reduce gastroesophageal reflux (GER) symptoms in infants by making the formula heavier and less likely to reflux back into the esophagus. However, this should only be done under the guidance of a healthcare provider to ensure proper preparation and feeding technique. 'I will keep my baby in an upright position after feedings.' - This statement indicates an understanding of the teaching. Keeping the baby in an upright position after feedings can help reduce reflux symptoms by allowing gravity to keep the stomach contents down. Parents can hold the baby upright on their shoulder or in an infant seat for a period of time after feeding to minimize reflux episodes.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Monitor the client's hemoglobin level
- B. Restrain the client's extremities
- C. Place the client in a prone position
- D. Record the time and length of the seizure
Correct Answer: D
Rationale: Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.
Bacterial infection caused by both staph and strept bacteria. Usually sign around mouth and nose, more common in children and the elderly.
- A. Eczema
- B. Vitiligo
- C. Angioedema
- D. Impetigo
Correct Answer: D
Rationale: Eczema: Eczema is a chronic skin condition characterized by inflammation, redness, and itching. It is not typically caused by bacterial infections and does not present with signs around the mouth and nose. Vitiligo: Vitiligo is a condition characterized by the loss of skin color in patches. It is not caused by bacterial infections and does not typically present with signs around the mouth and nose. Angioedema: Angioedema is swelling beneath the skin, often around the eyes and lips, and is commonly associated with allergic reactions or other triggers. It is not caused by bacterial infections. Impetigo: Impetigo is a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes bacteria. It commonly presents with red sores or blisters around the mouth and nose, especially in children and the elderly. Therefore, option D, Impetigo, is the correct answer.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Move the child into a side-lying position.
- B. Place a pillow under the child's head.
- C. Time the seizure.
- D. Remove the child's eyeglasses.
Correct Answer: A
Rationale: Move the child into a side-lying position: This action is crucial during a seizure with vomiting to prevent aspiration. Placing the child on their side helps ensure that any vomit can easily exit the mouth and reduces the risk of choking or aspiration into the lungs. Place a pillow under the child's head: While providing comfort is important, it is not the priority during a seizure with vomiting. Placing a pillow under the child's head might elevate the head slightly, but it doesn't address the risk of aspiration, which is the primary concern. Time the seizure: Timing the seizure is important for documentation and to monitor the duration of the seizure. However, it is not the priority during the active phase of the seizure, especially when vomiting is occurring. Remove the child's eyeglasses: Removing the child's eyeglasses is not a priority during a seizure with vomiting. While it's important to prevent injury, particularly to the eyes, during a seizure, the immediate concern is addressing the risk of aspiration caused by vomiting.