Nokea
A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority?
- A. Constipation
- B. Sedation
- C. Bradypnea
- D. Euphoria
Correct Answer: C
Rationale: The correct answer is C: Bradypnea. This is the priority finding because morphine, an opioid, can cause respiratory depression leading to bradypnea or slow breathing. Monitoring the child's respiratory status is crucial to prevent respiratory compromise or arrest. A: Constipation is a common side effect but not an immediate concern. B: Sedation is expected after receiving morphine but not as critical as respiratory depression. D: Euphoria is a possible side effect but not as concerning as respiratory depression. Thus, the priority is to monitor for signs of respiratory depression to ensure the child's safety.
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A 7-year-old obese child was diagnosed at his 6-year primary care visit with idiopathic hypertension. The family was instructed to modify his diet and begin an exercise program to control the hypertension. At this visit, it was decided the child should begin a low dose of Lisinopril (Zestril) at 0.07 mg/kg/day. The child weighs 99 pounds. What is the correct dose for this child?
- A. 70 mg/day
- B. 30 mg/day
- C. 6 mg/day
- D. 3 mg/day
Correct Answer: D
Rationale: The correct dose for this child is 3 mg/day. To calculate the dose, we first need to convert the child's weight from pounds to kilograms by dividing by 2.2 (99 lbs / 2.2 = 45 kg). Next, we multiply the weight in kg by the prescribed dosage of 0.07 mg/kg/day (45 kg x 0.07 mg/kg/day = 3.15 mg/day). Since the dosing is typically rounded down for safety reasons, the correct dose is 3 mg/day.
Choice A (70 mg/day) is incorrect because it is too high for a child of this weight and could lead to adverse effects. Choice B (30 mg/day) is also too high. Choice C (6 mg/day) is incorrect as it does not reflect the calculated dosage based on the weight of the child. Therefore, the correct answer is D (3 mg/day) based on the calculated dosage per kg for this specific child.
Which is the correct positioning of a child experiencing epistaxis:
- A. The child should be placed in a prone position
- B. The child should be placed in a supine position
- C. The child should be sitting with their head tilted back
- D. The child should sit up and lean forward
Correct Answer: D
Rationale: The correct positioning for a child experiencing epistaxis (nosebleed) is option D: the child should sit up and lean forward. This position helps prevent blood from flowing down the throat, reducing the risk of choking or aspiration. Sitting up also helps to reduce blood pressure in the vessels of the nose, aiding in the clotting process. Placing the child in a prone position (option A) can lead to blood flowing down the throat, causing potential airway obstruction. Placing the child in a supine position (option B) can also lead to blood going down the throat and may increase the risk of aspiration. Sitting with the head tilted back (option C) is not recommended as it can lead to blood running down the back of the throat and potentially into the airway. Therefore, option D is the correct choice for managing epistaxis in a child.
The nurse is caring for a school aged child in sickle cell crisis. Which interventions are appropriate for this patient? (Select all that apply)
- A. Application of a heating pad to the painful areas
- B. Start a Morphine PCA to provide pain relief for this patient
- C. Encourage patient to ambulate often to prevent pneumonia
- D. Hydrate patient with one-and-a-half-time maintenance fluid
Correct Answer: A,B,D
Rationale: Correct Answer: A, B, D
Rationale:
A: Application of a heating pad to the painful areas helps to relieve vaso-occlusive pain in sickle cell crisis by promoting vasodilation and increasing blood flow.
B: Starting a Morphine PCA is appropriate for pain management in sickle cell crisis as it provides controlled analgesia for the patient.
D: Hydrating the patient with one-and-a-half-time maintenance fluid helps prevent dehydration and maintain adequate blood flow, reducing the risk of vaso-occlusive episodes.
Incorrect Choices:
C: Encouraging the patient to ambulate often may not be suitable during a sickle cell crisis as it can increase the risk of pain and further complications.
E, F, G: No additional choices given, but typically options not directly related to pain management, hydration, or symptom relief would be incorrect in this scenario.
The nurse is educating parents of a sickle cell patient regarding infection prevention. Which statement best indicates the parent understands the child's risk for infection?
- A. If the child has a fever, they need to stay home from school
- B. Antibiotics should be administered sparingly to prevent resistant infections in this population
- C. Children with sickle cell disease are at risk for infection due to impaired splenic function
- D. If the child is showing signs of crisis, a cup of hot tea can prevent the red blood cells from clumping rapidly
Correct Answer: C
Rationale: The correct answer is C. Children with sickle cell disease are at risk for infection due to impaired splenic function. This is because the spleen plays a crucial role in fighting infections, and individuals with sickle cell disease often have impaired splenic function, making them more susceptible to infections.
Explanation for other choices:
A: If the child has a fever, they need to stay home from school - While it is important for sickle cell patients to avoid exposure to infections, staying home from school only when the child has a fever does not address the overall risk of infection in these patients.
B: Antibiotics should be administered sparingly to prevent resistant infections in this population - While antibiotic resistance is a concern, the statement does not specifically address the child's risk for infection due to impaired splenic function.
D: If the child is showing signs of crisis, a cup of hot tea can prevent the red blood cells from clumping rapidly - This statement is incorrect as hot tea does not prevent
The nurse is providing education to the parents of an infant with cradle cap. Which of the following statements by the parents indicates their understanding?
- A. We should use hydrogen peroxide as shampoo for my child until it is resolved
- B. We should expect that my child will probably have asthma & allergies too
- C. We should brush the loosened crusts out of the hair after shampooing
- D. We should decrease the frequency that I wash my child's hair to once a week
Correct Answer: C
Rationale: The correct answer is C: "We should brush the loosened crusts out of the hair after shampooing." This statement indicates understanding as brushing the loosened crusts helps to remove the scales and prevent further build-up. Hydrogen peroxide (A) is not recommended for cradle cap as it can irritate the skin. Asthma and allergies (B) are not directly related to cradle cap. Decreasing hair wash frequency to once a week (D) can worsen cradle cap by allowing build-up of oils and dead skin cells.