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A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- A. Discourage the client from ambulating.
- B. Use a hair dryer on a hot setting to dry the cast.
- C. Keep the client's leg in a dependent position.
- D. Perform a neurovascular check of the lower extremities.
Correct Answer: D
Rationale: Discouraging the client from ambulating is not the best action. While it's important to limit weight-bearing activities initially, movement is encouraged to promote circulation and prevent complications such as deep vein thrombosis. Using a hair dryer on a hot setting to dry the cast is not recommended. Heat can cause the cast to dry out and crack, and it can also burn the skin. Keeping the client's leg in a dependent position is not advisable. This can lead to increased swelling and pain, and potentially delay healing. Performing a neurovascular check of the lower extremities is the correct action. This involves assessing for pain, pallor, pulselessness, paresthesia, and paralysis. These checks are crucial for monitoring for complications such as compartment syndrome and ensuring the cast is not too tight.
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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 is providing guidance to a toddler's parent about the types of food that are part of a clear liquid diet. Which food, if suggested by the parent, would indicate that they have understood the instructions?
- A. Yogurt
- B. Gelatin
- C. Strained soup
- D. Pureed fruit
Correct Answer: B
Rationale: Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature. Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature. Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed. Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- B. Collect a stool sample from the toddler.
- C. Determine if the toddler is voiding.
- D. Request evaluation of the toddler's serum electrolytes.
Correct Answer: C
Rationale: Initiate isotonic fluids with 20 mEq/L potassium chloride. While it is important to maintain hydration in a child with acute gastroenteritis, initiating isotonic fluids with 20 mEq/L potassium chloride is not the first action a nurse should take. The child's hydration status and electrolyte balance need to be assessed first. The American Academy of Pediatrics recommends the use of isotonic solutions with adequate potassium chloride and dextrose for maintenance IV fluids in children. Collect a stool sample from the toddler Collecting a stool sample can help identify the cause of the gastroenteritis. However, this is not the first step. The stool sample collection should be done using a clean, dry toilet hat or plastic wrap. But before this, the child's hydration status needs to be assessed. Determine if the toddler is voiding The first action the nurse should take when using the nursing process is assessment. Therefore, checking if the toddler is voiding is the priority. This will help assess the child's hydration status, which is critical in managing acute gastroenteritis. Request evaluation of the toddler's serum electrolytes Requesting an evaluation of the toddler's serum electrolytes is also important, but it's typically done after the initial assessment. Fluid and electrolyte derangement are the immediate causes that increase the mortality in diarrhea. However, before requesting this evaluation, the nurse should first determine if the toddler is voiding to assess the child's hydration status.
Your child will need to increase his calcium intake to 3,000 milligrams daily. A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching?
- A. Bone marrow can be lost through the fracture.
- B. Fractures in a child take longer to heal than fractures in an adult.
- C. Normal bone growth can be affected by the fracture.
- D. The child will need to increase his calcium intake to 3,000 milligrams daily.
Correct Answer: C
Rationale: While it's true that bone marrow can be lost through a fracture, this is not specific to fractures of the epiphyseal plate. The healing time for fractures in children and adults can vary depending on many factors, but it's not accurate to say that fractures in children take longer to heal than fractures in adults. Normal bone growth can indeed be affected by a fracture of the epiphyseal plate. The epiphyseal plate, or growth plate, is the area of growing tissue near the ends of the long bones in children and adolescents. When a fracture occurs at the epiphyseal plate, it can disrupt the normal growth of the bone and lead to deformities. While calcium is important for bone health, increasing a child's calcium intake to 3,000 milligrams daily is not typically recommended as part of the treatment or management of a fracture.
A nurse is caring for a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that a common characteristic associated with nephrotic syndrome is:
- A. Hypotension
- B. Generalized edema
- C. Increased urinary output
- D. Bright red blood in urine
Correct Answer: B
Rationale: Hypotension, or low blood pressure, is not typically associated with nephrotic syndrome. In fact, some patients with nephrotic syndrome may experience high blood pressure. Generalized edema, or swelling, is a common characteristic of nephrotic syndrome. It occurs due to the loss of proteins in the urine, which leads to a decrease in the amount of protein in the blood. This decrease in blood protein levels causes fluid to move from the blood vessels into the tissues, leading to swelling. Increased urinary output is not typically associated with nephrotic syndrome. In fact, some patients may experience decreased urine output. Bright red blood in the urine is not a typical symptom of nephrotic syndrome. Hematuria, or blood in the urine, when present in nephrotic syndrome, is usually microscopic and not visible to the naked eye.