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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.
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An infant who has developmental dysplasia of the hip (DDH)
A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Lengthened thigh on the affected side
- C. Absent plantar reflexes
- D. Asymmetric thigh folds
Correct Answer: A,D
Rationale: The correct answers are A and D. In DDH, an inwardly turned foot on the affected side (A) is expected due to hip dislocation. Asymmetric thigh folds (D) are also common as the affected thigh may appear shorter due to dislocation. Lengthened thigh (B) is incorrect as the thigh may appear shortened. Absent plantar reflexes (C) are not typical in DDH.
A school-age child who has respiratory failure due to pneumonia
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
- A. Upright
- B. Supine
- C. Prone
- D. Side-lying
Correct Answer: A
Rationale: The correct answer is A: Upright. In an upright position, gravity helps to maximize lung expansion by allowing the diaphragm to descend fully. This position promotes better ventilation and oxygenation by reducing the pressure on the lungs. Supine (B), prone (C), and side-lying (D) positions can limit lung expansion and compromise breathing mechanics. These positions may cause the abdominal contents to compress the lungs, reducing their ability to expand fully. Therefore, encouraging the child to sit upright will optimize lung function and promote effective gas exchange.
A toddler receiving ear drops
While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, 'Why are you pulling the ear that way?' Which of the following responses should the nurse make?
- A. When I use this technique the medication will not run out of the ear.
- B. This opens the ear canal, allowing medication to reach the inner ear region.
- C. This is the safest and easiest way to administer this medication.
- D. When I use the technique, your child experiences less pain.
Correct Answer: B
Rationale: The correct answer is B: This opens the ear canal, allowing medication to reach the inner ear region. By pulling the auricle down and back, the nurse straightens the ear canal in toddlers, making it easier for the ear drops to reach the inner ear where they are most effective. This technique helps ensure that the medication is properly administered and absorbed.
Incorrect Answers:
A: When I use this technique the medication will not run out of the ear - This is incorrect because the aim of pulling the ear is not to prevent medication from running out but to facilitate its entry.
C: This is the safest and easiest way to administer this medication - This is incorrect as the safety and ease of administration are not the primary reasons for pulling the ear in this context.
D: When I use the technique, your child experiences less pain - This is incorrect as the main purpose of pulling the ear is not to reduce pain but to ensure effective delivery of the medication to the inner ear.
A child who is postoperative following the insertion of a ventriculoperitoneal shunt
A nurse is caring for a child who is postoperative following the insertion of a ventriculoperitoneal shunt. The nurse should place the child in which of the following positions?
- A. A 45 degree head elevation
- B. On the nonoperative side
- C. Prone
- D. Supine
Correct Answer: D
Rationale: The correct answer is D: Supine. Placing the child in a supine position promotes proper drainage and prevents obstruction of the ventriculoperitoneal shunt. Supine position helps maintain a neutral head position, reducing the risk of complications. A 45-degree head elevation (choice A) can increase intracranial pressure, which is contraindicated in this case. Placing the child on the nonoperative side (choice B) or prone (choice C) can potentially cause kinking or obstruction of the shunt tubing.
An 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis
A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?
- A. Drink eight glass of fluid daily.
- B. Maintain an updated hemophilus influence type b immunisation
- C. Avoid playground activities at school
- D. Assume postural drainage positions every 6 hrs
Correct Answer: A
Rationale: The correct answer is A: Drink eight glasses of fluid daily. This is crucial for children with sickle cell anemia to prevent dehydration, which can trigger vaso-occlusive crises. Adequate hydration helps maintain blood flow and prevent sickling of red blood cells. Maintaining an updated hemophilus influenzae type b immunization (choice B) is important for preventing infections but is not directly related to vaso-occlusive crises. Avoiding playground activities at school (choice C) is unnecessary as long as the child is careful and stays hydrated. Assuming postural drainage positions every 6 hours (choice D) is not relevant for sickle cell anemia management.