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A child who has Kawasaki disease
A nurse is caring for a child who has Kawasaki disease. Which of the following systems is primarily affected by this disease?
- A. Respiratory
- B. Gastrointestinal
- C. Cardiovascular
- D. Integumentary
Correct Answer: C
Rationale: The correct answer is C: Cardiovascular. Kawasaki disease primarily affects the cardiovascular system, causing inflammation of blood vessels, particularly the coronary arteries. This can lead to complications such as coronary artery aneurysms and myocarditis. The other choices are incorrect because Kawasaki disease does not primarily affect the respiratory, gastrointestinal, or integumentary systems. The key feature of Kawasaki disease is the inflammation of blood vessels, which is why the cardiovascular system is the primary system affected.
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An infant who has Tetralogy of Fallot and is easily fatigued when eating
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
- A. Overriding aorta
- B. Pulmonary stenosis
- C. Left ventricular hypertrophy
- D. Ventricular septal defect
Correct Answer: C
Rationale: The correct answer is C: Left ventricular hypertrophy is not present in Tetralogy of Fallot. In Tetralogy of Fallot, the four main defects are pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. Left ventricular hypertrophy is not part of the condition. The infant's fatigue during feeding is likely due to decreased oxygen levels in the blood caused by the pulmonary stenosis and right-to-left shunting at the ventricular septal defect. Choices A, B, and D are all components of Tetralogy of Fallot, making them incorrect options.
A child who is experiencing an acute asthma attack
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
- A. Methylprednisolone
- B. Albuterol
- C. Fluticasone
- D. Beclomethasone
Correct Answer: B
Rationale: The correct answer is B: Albuterol. During an acute asthma attack, bronchodilation is crucial to relieve airway constriction quickly. Albuterol is a short-acting beta-agonist that acts rapidly to relax the airway muscles, allowing for improved airflow. Methylprednisolone (A) is a corticosteroid that is used for long-term control, not for immediate relief. Fluticasone (C) and Beclomethasone (D) are inhaled corticosteroids for maintenance therapy and do not provide immediate relief during an acute attack. Administering Albuterol first is essential to address the acute symptoms and stabilize the child's condition.
A child who has iron deficiency anemia
A nurse in a pediatric clinic in caring for a child who has iron deficiency anemia and is to start taking ferrous sulfate syrup. Which of the following Instructions should the nurse give the parent?
- A. Administer the medication at meal time
- B. Administer the medication at bedtime.
- C. Offer the medication through a straw
- D. Dilute the medication with 240 mi. (Bar) of milk
Correct Answer: C
Rationale: The correct answer is C: Offer the medication through a straw. This is because iron supplements can stain teeth, and using a straw can help minimize direct contact with the teeth, reducing the risk of staining. Administering the medication at mealtime (choice A) may cause gastrointestinal upset, and administering it at bedtime (choice B) may increase the risk of staining teeth during sleep. Diluting the medication with milk (choice D) is not recommended as calcium in milk can interfere with iron absorption. Offering the medication through a straw is the best option to ensure effective administration while minimizing side effects.
An infant with a large patent ductus arteriosus
A nurse is collecting data from an infant a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Machine like murmur
- B. Chronic hypoxemia
- C. Cyanosis with crying
- D. Weak pulse
Correct Answer: A
Rationale: The correct answer is A: Machine-like murmur. A patent ductus arteriosus (PDA) is a congenital heart defect where a blood vessel called the ductus arteriosus fails to close after birth, causing abnormal blood flow. The characteristic murmur associated with PDA is described as machine-like due to its continuous and loud nature. This murmur is heard best at the upper left sternal border. Other choices are incorrect because chronic hypoxemia (B) and cyanosis with crying (C) are more commonly seen in conditions like Tetralogy of Fallot or transposition of great vessels. Weak pulse (D) may be present in conditions like coarctation of the aorta.
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.