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A hospitalized 2-year-old child who has a tantrum when a parent leaves
A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take?
- A. Give the child a stuffed animal.
- B. Inform the child that her parent will be back in 2 hr.
- C. Call the parent to return to the child's room.
- D. Leave the child alone in the room for 5 min.
Correct Answer: A
Rationale: The correct answer is A: Give the child a stuffed animal. Offering the child a stuffed animal can provide comfort and a sense of security, helping to calm the child during the parent's absence. This action promotes emotional support and may help to reduce the child's anxiety.
Other choices are incorrect:
B: Informing the child about the parent's return time may not effectively address the immediate emotional distress.
C: Calling the parent back may not be feasible or necessary for every instance of separation anxiety.
D: Leaving the child alone can exacerbate feelings of fear and abandonment, potentially escalating the tantrum.
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Which of the following techniques help prepare a child for surgery by utilising role playing or hands on activities (eg, starting an IV on a teddy bears)?
- A. Onlooker play
- B. Therapeutic play
- C. Cooperative play
- D. Play therapy
Correct Answer: B
Rationale: The correct answer is B: Therapeutic play. Therapeutic play involves using various activities like role-playing or hands-on tasks to help children understand and cope with medical procedures. It allows them to express emotions, reduce anxiety, and gain a sense of control. Onlooker play (A) involves observing others play without actively participating. Cooperative play (C) involves playing together towards a common goal. Play therapy (D) is a form of psychotherapy using play to help children express feelings. Since the question specifically mentions preparing a child for surgery through role-playing and hands-on activities, therapeutic play is the most appropriate choice.
An adolescent who is having a sickle cell crisis
A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
- A. withhold opioids to avoid dependence
- B. Assist RN with administering a blood transfusion
- C. Initiate a 2 L/day fluid restriction
- D. Encourage exercise
Correct Answer: B
Rationale: The correct answer is B: Assist RN with administering a blood transfusion. During a sickle cell crisis, blood transfusions can help improve oxygen delivery to tissues by increasing the number of normal red blood cells. This can help alleviate symptoms and prevent complications. Withholding opioids (choice A) can lead to inadequate pain management. Initiation of fluid restriction (choice C) is inappropriate as hydration is crucial during a sickle cell crisis. Encouraging exercise (choice D) can worsen the crisis by increasing the risk of vaso-occlusive events.
A 2-month-old infant who has just undergone cleft palate repair
A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?
- A. Keep the infant in a side-lying position.
- B. Remove elbow restraints while the infant is sleeping
- C. Administer pain medication around the clock for the first 72 hr.
- D. Feed the infant half-strength formula for the first 48 hr
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
C: Administer pain medication around the clock for the first 72 hr to ensure adequate pain management post-cleft palate repair.
D: Feed the infant half-strength formula for the first 48 hr to prevent potential aspiration and promote healing.
Summary:
A: Keeping the infant in a side-lying position is not directly related to cleft palate repair care.
B: Removing elbow restraints while the infant is sleeping may increase the risk of self-injury.
E, F, G: No additional information provided, so cannot determine their relevance.
A client who is postoperative immediately following a tonsillectomy
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the flowing snacks should the nurse offer the client?
- A. Cranberry juice
- B. Ice-cream
- C. Hot tea
- D. Italian ice
Correct Answer: B,D
Rationale: The correct snacks to offer a client post-tonsillectomy are ice-cream and Italian ice. Ice-cream is soft, cold, and soothing, helping to reduce pain and inflammation. Italian ice is also cold and can provide relief. Cranberry juice and hot tea are acidic and may irritate the surgical site. Ice-cream and Italian ice are the best choices as they are gentle on the throat and provide comfort without causing discomfort.
A child who has cystic fibrosis
A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will restrict the amount of salt in my child's meals.
- B. I will put my child in daycare to ensure that she socializes with other children.
- C. I will make sure my child washes her hands before eating.
- D. I will provide low-fat meals for my child.
Correct Answer: C
Rationale: The correct answer is C: "I will make sure my child washes her hands before eating." This statement indicates an understanding of the teaching because proper handwashing is crucial in preventing infections in individuals with cystic fibrosis who are more susceptible to respiratory infections. By washing hands before eating, the child can reduce the risk of exposure to harmful pathogens.
Choice A is incorrect because restricting salt intake is not a priority in managing cystic fibrosis. Choice B is incorrect as the focus should be on hygiene and health rather than socialization. Choice D is incorrect as children with cystic fibrosis actually require a higher calorie and fat intake.