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A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?
- A. Maintain a saline-lock.
- B. Check the child's weight daily.
- C. Place the child on a no-salt-added diet.
- D. Educate the parents about potential complications.
Correct Answer: B
Rationale: Maintain a saline-lock: While maintaining a saline lock is important for ensuring vascular access in case of emergency, it is not the priority action in caring for a child with acute glomerulonephritis. Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action. Place the child on a no-salt-added diet: Dietary modifications, including reducing salt intake, may be recommended for managing acute glomerulonephritis. However, it is not the priority action at this stage. Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.
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A nurse is checking a school-age child for pediculosis capitis. Which of the following findings is a definitive indication of this condition?
- A. Firmly attached white particles on the hair
- B. Itching and scratching of the head
- C. Thick, yellow-crusted lesions on a red base
- D. Patchy areas of hair loss
Correct Answer: A
Rationale: Firmly attached white particles on the hair: Firmly attached white particles on the hair are characteristic of nits, which are the eggs of lice. While this finding supports the diagnosis of pediculosis capitis, it is not a definitive indication on its own. Itching and scratching of the head: Itching and scratching of the head are common symptoms of pediculosis capitis. However, they are also common symptoms of various other scalp conditions, so they are not definitive indications. Thick, yellow-crusted lesions on a red base: This description is more characteristic of impetigo, a bacterial skin infection, rather than pediculosis capitis. Impetigo typically presents with yellow-crusted lesions on a red base, but it does not involve lice infestation. Patchy areas of hair loss: Patchy areas of hair loss are not typically associated with pediculosis capitis. This finding is more suggestive of conditions like alopecia areata or fungal infections.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Change to cloth diapers until the skin is healed.
- B. Use a moisturizer to wipe urine from the skin.
- C. Apply a light layer of talcum powder with each diaper change.
- D. Expose the excoriated area to hot air frequently.
Correct Answer: B
Rationale: While some parents may prefer cloth diapers, they can retain moisture and irritants. Disposable diapers with good absorbency are often preferred in managing diaper dermatitis. Using a gentle moisturizer to clean the skin can help protect the infant's skin and maintain its barrier function, especially in cases of diaper dermatitis. Moisturizers help soothe and heal the affected area by providing hydration and protection. Talcum powder is not recommended due to the risk of inhalation, which can cause respiratory issues. Additionally, powders can clump and worsen skin irritation. Exposing the skin to hot air can dry out the skin and worsen irritation. It's better to allow the area to air-dry naturally or use a cool blow dryer on a low setting.
A 24 month old comes into the clinic to get his first flu vaccination. The nurse notices what food allergy in the patient's chart that would make this vaccine contraindicated?
- A. Gelatin
- B. Peanuts
- C. Eggs
- D. Bee Venom
Correct Answer: C
Rationale: Gelatin: Gelatin is sometimes used as a stabilizer in vaccines, including some flu vaccines. Individuals with severe gelatin allergies may need to avoid vaccines containing gelatin. However, egg allergy is more common and directly relevant to the contraindication for flu vaccination. Peanuts: Peanuts are not typically used in the production of flu vaccines. Peanut allergies are not a contraindication for flu vaccination unless the person also has an egg allergy or another contraindication. Eggs: Flu vaccines are commonly produced using chicken eggs. Therefore, individuals with a severe egg allergy should avoid flu vaccines, as they may experience an allergic reaction. This is especially important for young children, as they may be more prone to severe allergic reactions. Bee Venom: Bee venom is not an ingredient in flu vaccines. While it's essential to consider allergies to various substances when administering vaccines, bee venom allergy does not impact the safety of flu vaccination.
A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Increased appetite
- C. Mucus in stools
- D. Jaundice
Correct Answer: C
Rationale: Drooling - Drooling is not typically associated with intussusception. Intussusception is a condition where one portion of the intestine telescopes into another, leading to bowel obstruction and subsequent symptoms such as abdominal pain, vomiting, and 'currant jelly' stools. Increased appetite - Increased appetite is unlikely in a toddler with intussusception. Instead, affected toddlers may experience symptoms such as abdominal pain, vomiting, and lethargy, which can lead to decreased appetite. Mucus in stools - Mucus in stools is a characteristic finding in intussusception. As the telescoping of the intestine causes irritation and inflammation, mucus may be passed in the stool along with blood and, in some cases, a characteristic 'currant jelly' appearance. Jaundice - Jaundice is not a typical manifestation of intussusception. It may be present in conditions affecting the liver or bile ducts, such as biliary atresia or obstructive jaundice, but it is not a direct symptom of intussusception.
The nurse is caring for a 7-year-old child who fell off an ATV sustaining a flesh wound. The child is awaiting wound debridement. What nursing action best demonstrates the concept of atraumatic care?
- A. Allowing siblings to visit the client in the hospital
- B. Using a doll to demonstrate an invasive procedure
- C. Encouraging communication between the parents and nurse
- D. Arranging the room to accommodate religious practices
Correct Answer: B
Rationale: Allowing siblings to visit the client in the hospital - Allowing siblings to visit the client in the hospital is a compassionate gesture and promotes family-centered care. However, it may not directly address the concept of atraumatic care, which focuses on minimizing physical and psychological stress related to healthcare procedures. Using a doll to demonstrate an invasive procedure - Using a doll to demonstrate an invasive procedure is an example of atraumatic care. It allows the nurse to provide preparatory information to the child in a non-threatening and understandable manner. By visually demonstrating the procedure on a doll, the child can better understand what will happen, reducing anxiety and fear. Encouraging communication between the parents and nurse - Encouraging communication between the parents and nurse is important for providing holistic care and addressing the child's needs. While effective communication is essential, it may not directly demonstrate the concept of atraumatic care unless it involves discussing how to minimize stress and anxiety during procedures. Arranging the room to accommodate religious practices - Arranging the room to accommodate religious practices is a form of patient-centered care and respects the cultural and religious beliefs of the patient and family. While important for overall comfort and respect for the patient's values, it may not directly relate to the concept of atraumatic care, which specifically focuses on reducing stress and anxiety during healthcare procedures.