Nokea
A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to assess?
- A. Quality of the cry
- B. Signs of dehydration
- C. Coughing up feedings
- D. Characteristics of the stool
Correct Answer: B
Rationale: The correct answer is B: Signs of dehydration. Infants with hypertrophic pyloric stenosis (HPS) are at high risk of dehydration due to frequent vomiting. Assessing for signs of dehydration, such as decreased urine output, dry mucous membranes, and sunken fontanelles, is crucial for early intervention and management. Choices A, C, and D are not the most critical assessments for HPS. The quality of the cry (choice A) may not provide as much relevant information in this case. Coughing up of feedings (choice C) may be a symptom but is not as crucial as assessing for dehydration. Characteristics of the stool (choice D) are important but assessing for signs of dehydration takes precedence due to the immediate risk it poses to the infant's health.
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A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect?
- A. Proteinuria
- B. Peripheral edema
- C. Elevated hematocrit
- D. Absence of pedal pulses
Correct Answer: C
Rationale: In a child with a congenital cardiac malformation causing right-to-left shunting of blood, the nurse should expect an elevated hematocrit. This occurs because the body compensates for decreased oxygenation by producing more red blood cells. Proteinuria (Choice A) is not a typical clinical finding related to right-to-left shunting. Peripheral edema (Choice B) is more commonly associated with conditions causing volume overload, such as left-sided heart failure. Absence of pedal pulses (Choice D) is not directly related to right-to-left shunting but may be seen in conditions affecting peripheral circulation.
A child has been diagnosed with classic hemophilia. A nurse teaches the child's parents how to administer the plasma component factor VIII through a venous port. It is to be given 3 times a week. What should the nurse tell them about when to administer this therapy?
- A. Whenever a bleed is suspected
- B. In the morning on scheduled days
- C. At bedtime while the child is lying quietly in bed
- D. On a regular schedule at the parents' convenience
Correct Answer: B
Rationale: Administering factor VIII in the morning on scheduled days is the correct choice. This timing ensures that the factor VIII levels remain stable throughout the day when the child is active and at risk of bleeding. Choice A is incorrect because factor VIII should be given on a regular schedule rather than only when a bleed is suspected. Choice C is not ideal as the child may be more active during the day, increasing the risk of bleeding. Choice D is also incorrect as the administration should follow a specific schedule to maintain therapeutic levels of factor VIII in the child's system.
A child with a diagnosis of asthma is being cared for by a nurse. What is an important nursing intervention?
- A. Administering bronchodilators
- B. Encouraging physical activity
- C. Monitoring oxygen saturation
- D. Providing nutritional support
Correct Answer: A
Rationale: Administering bronchodilators is a crucial nursing intervention for a child with asthma because it helps to open the airways and ease breathing during an asthma attack. Bronchodilators are medications that work by relaxing the muscles around the airways, making it easier for the child to breathe. Encouraging physical activity may exacerbate asthma symptoms in some cases due to increased respiratory effort and exposure to triggers. Monitoring oxygen saturation is important but does not address the immediate need of opening the airways during an asthma episode. Providing nutritional support is essential for overall health but is not the primary intervention needed in managing an acute asthma exacerbation.
A child with a diagnosis of congenital heart disease is admitted to the hospital. What should the nurse include in the child's care plan?
- A. Monitoring fluid status
- B. Encouraging activity
- C. Promoting a high-calorie diet
- D. Maintaining oxygen therapy
Correct Answer: A
Rationale: Monitoring fluid status is crucial for a child with congenital heart disease because these children are at risk of fluid overload, which can exacerbate their condition. Monitoring fluid intake and output helps prevent complications such as heart failure. Encouraging activity may be important, but it should be done cautiously and within limits due to the child's cardiac condition. Promoting a high-calorie diet is not typically a priority in congenital heart disease care unless there are specific indications. Maintaining oxygen therapy may be necessary in some cases but is not the primary intervention for managing congenital heart disease.
The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults?
- A. Most childhood cancers affect tissues rather than organs.
- B. Childhood cancers are usually localized when found.
- C. Unlike adult cancers, childhood cancers are less responsive to treatment.
- D. The majority of childhood cancers can be prevented.
Correct Answer: A
Rationale: The correct answer is A. Most childhood cancers, such as leukemias and sarcomas, affect tissues rather than specific organs, unlike many adult cancers. Choice B is incorrect because childhood cancers may not always be localized when found. Choice C is incorrect as childhood cancers can be responsive to treatment, although treatment approaches may differ from adult cancers. Choice D is incorrect as the majority of childhood cancers cannot be prevented; however, certain risk factors can be managed to reduce the risk of developing cancer.