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A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive crisis. Which of the following actions should the nurse take?
- A. Apply cold compresses to the affected areas.
- B. Prepare for a transfusion of platelets.
- C. Promote active range of motion exercises.
- D. Increase oral fluid intake.
Correct Answer: D
Rationale: The correct answer is D: Increase oral fluid intake. During a vaso-occlusive crisis in sickle cell anemia, there is a blockage of blood flow leading to tissue ischemia and pain. Increasing oral fluid intake helps to hydrate the child and improve blood flow, potentially reducing the severity of the crisis. Cold compresses (A) can worsen vasoconstriction, platelet transfusion (B) is not indicated for vaso-occlusive crisis, and active range of motion exercises (C) can exacerbate pain and further compromise blood flow. Increasing fluid intake is the most appropriate intervention to help manage the crisis.
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A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Nontender, protruding abdomen
- C. Natural loss of deciduous teeth
- D. Palpable fontanels
Correct Answer: B
Rationale: The correct answer is B: Nontender, protruding abdomen. In toddlers, it is normal to have a nontender, protruding abdomen due to the physiological characteristics of their developing digestive system and musculature. This is because toddlers have less developed abdominal muscles and a larger liver in proportion to their body size, causing their abdomen to appear slightly distended. This finding is considered normal and does not typically indicate any underlying health issues. The other options are incorrect because: A: Head circumference exceeding chest circumference is not a typical finding in a 2-year-old toddler. C: Natural loss of deciduous teeth typically occurs around age 6-7, not in toddlers. D: Fontanels should be closed by 18 months, so palpable fontanels in a 2-year-old would be abnormal.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room
- B. Administer aspirin to the child for fever
- C. Use droplet precautions when caring for the child
- D. Assess the child for health spots
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella (chickenpox) is highly contagious and spreads through airborne particles. Placing the child in a negative air pressure room helps prevent the spread of the virus to other patients and staff. Administering aspirin to a child with varicella can lead to Reye's syndrome, making choice B incorrect. Droplet precautions are used for illnesses like influenza or pertussis, not varicella, so choice C is incorrect. Choice D is incorrect because the characteristic rash in varicella is not described as health spots.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the epiglottis becomes inflamed and can lead to airway obstruction. Intubation may be necessary to secure the airway and ensure the child can breathe. It is a priority action to maintain the child's oxygenation and ventilation. Obtaining a throat culture (B) can be important for diagnosis but is not the immediate priority. Suctioning the child's oropharynx (C) can trigger a spasm and worsen the obstruction. Cool mist tent (D) is not indicated in the management of epiglottitis.
A nurse is caring for a 9-year-old at a clinic. The nurse reviews the assessment findings. Select findings that require immediate follow up. Select all that apply.
- A. Right forearm and fingers are edematous
- B. Abdomen non-distended
- C. Fingers slightly cool to touch
- D. Oxygen saturation 98% on room air
- E. Heart rate 102/min
- F. Respiratory rate 22/min
- G. Ecchymotic area noted on outer aspect of the forearm
Correct Answer: A,C,E,F
Rationale: The correct answers are A, C, E, and F.
A: Edematous right forearm and fingers can indicate a potential circulatory issue requiring immediate follow-up.
C: Fingers slightly cool to touch suggest poor circulation, requiring further assessment.
E: Heart rate of 102/min in a 9-year-old is above normal, indicating possible distress.
F: Respiratory rate of 22/min is slightly elevated and could indicate respiratory distress.
B, D, G are not immediate concerns as a non-distended abdomen, oxygen saturation of 98% on room air, and an ecchymotic area on the forearm do not require immediate follow-up in this context.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Fever
- B. Steatorrhea
- C. Tinnitus
- D. Dysphagia
Correct Answer: A
Rationale: The correct answer is A: Fever. Bacterial pneumonia commonly presents with fever due to the body's immune response to the infection. This is a classic sign of inflammation caused by the bacterial infection in the lungs. Steatorrhea (B), tinnitus (C), and dysphagia (D) are not typical manifestations of bacterial pneumonia. Steatorrhea is associated with malabsorption disorders, tinnitus is often related to ear issues, and dysphagia is difficulty swallowing, which is not a common symptom of pneumonia. Therefore, the nurse should expect fever as a key manifestation of bacterial pneumonia in the child.