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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. Place the child on a no-salt-added diet.
- C. Check the child's weight daily.
- D. Educate the parents about potential complications.
Correct Answer: C
Rationale: While maintaining a saline-lock can be important for administering medications or fluids, it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. A no-salt-added diet may be recommended for some children with acute glomerulonephritis to help manage fluid balance and blood pressure. However, this is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications. This is the correct answer. Checking the child's weight daily is a priority action because weight changes can indicate fluid retention or loss, which can affect kidney function. Regular weight checks can help guide treatment decisions and monitor the effectiveness of interventions. Educating the parents about potential complications is important, but it is not the priority action. The nurse's priority should be to assess the child's condition and intervene to prevent complications.
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The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis?
- A. Abdominal rigidity and pain on palpation.
- B. Rounded abdomen and hypoactive bowel sounds.
- C. Visible peristalsis and weight loss.
- D. Distention of the lower abdomen and constipation.
Correct Answer: B
Rationale: Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped mass in the upper abdomen, and signs of dehydration. A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting. The infant may appear hungry after vomiting and will continue to feed, leading to weight loss. Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible peristalsis occurs as the infant tries to force the stomach contents through the narrowed pyloric sphincter. Weight loss is a result of poor feeding and vomiting. Distention of the lower abdomen and constipation are not typical findings in pyloric stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis primarily affects the upper gastrointestinal tract.
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. Patchy areas of hair loss
- D. Thick yellow-crusted lesions on a red base
Correct Answer: A
Rationale: Pediculosis capitis, also known as head lice, is a common condition in children. One of the definitive indications of this condition is the presence of firmly attached white particles on the hair, which are the eggs or 'nits' of the lice. While itching and scratching of the head can be a symptom of pediculosis capitis, it is not a definitive indication as it can be caused by other conditions such as dandruff or dermatitis. Patchy areas of hair loss are not typically associated with pediculosis capitis. They could indicate a different condition, such as alopecia areata or tinea capitis. Thick yellow-crusted lesions on a red base are not a symptom of pediculosis capitis. This description is more consistent with impetigo, a bacterial skin infection.
Which statement from a parent of a 1-month-old infant undergoing initial surgery for Hirschsprung's disease indicates understanding of the surgery's goal?
- A. I'm glad that the ostomy is only temporary.'
- B. The operation will straighten out the kink in the intestine.'
- C. I want to learn how to use the feeding tube as soon as possible.'
- D. I'm glad my child will have normal bowel movements now.'
Correct Answer: A
Rationale: The goal of surgery for Hirschsprung disease is to remove the diseased section of the intestine and then pull the healthy portion of this organ down to the anus. This is typically achieved through a type of surgery called a pull-through procedure. In some cases, doctors recommend ostomy surgery of the bowel followed by a pull-through procedure. During ostomy surgery, surgeons create a stoma on a child's abdomen and connect the stoma to the large or small intestine. After ostomy surgery, waste will leave the child's body through the stoma. The stoma is usually temporary. In most cases, surgeons can later close the stoma and connect the healthy part of the intestine to the anus. Waste will move through the intestines, and stool will pass through the anus again. Therefore, the statement 'I'm glad that the ostomy is only temporary' indicates understanding of the surgery's goal. The operation for Hirschsprung's disease does not involve straightening out a kink in the intestine. Instead, it involves removing the part of the large intestine that is missing nerve cells and then connecting the healthy part of the large intestine to the anus. The use of a feeding tube is not typically associated with the initial surgery for Hirschsprung's disease. The surgery involves removing the diseased section of the intestine and then pulling the healthy portion of this organ down to the anus. While the ultimate goal of the surgery is to enable normal bowel movements, it is important to note that about half of children may have ongoing problems after surgery. These problems may include constipation and, in some cases, other symptoms of intestinal obstruction, such as a swollen abdomen or vomiting.
A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect?
- A. Mucus and blood in stools.
- B. Increased appetite.
- C. Jaundice.
- D. Drooling.
Correct Answer: A
Rationale: Mucus and blood in stools, often described as 'currant jelly' stools, are a common symptom of intussusception. Increased appetite is not typically associated with intussusception. In fact, children with this condition may experience decreased appetite due to abdominal pain. Jaundice is not a symptom of intussusception. Jaundice, a yellowing of the skin and eyes, is more commonly associated with liver conditions. Drooling is not a typical symptom of intussusception. Symptoms of intussusception are primarily gastrointestinal, including abdominal pain and bloody stools.
A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response?
- A. Follow the directions on the aspirin bottle for her age and weight.'
- B. She should be given acetaminophen, not aspirin.'
- C. Just be sure you administer the medication with food.'
- D. Give her no more than three baby aspirin every 4 hours.'
Correct Answer: B
Rationale: It's not advisable to follow the directions on the aspirin bottle for her age and weight. Aspirin is not recommended for use in children due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain. This is the correct response. Acetaminophen is a safer alternative to aspirin for managing fever in children. While it's generally a good idea to administer medication with food to prevent stomach upset, this advice does not address the specific risks associated with giving aspirin to a toddler. Giving a toddler three baby aspirin every 4 hours is not recommended due to the risk of Reye's syndrome.