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A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first?
- A. Tell the child what will happen to her when the abuse is reported.
- B. Request a social services referral.
- C. Report the suspected abuse to the authorities.
- D. Obtain a detailed history.
Correct Answer: D
Rationale: Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities. Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse. Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities. When a nurse notes the presence of bruises on a child's arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
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A nurse is providing instructions about methylphenidate (Ritalin) to the parents of a school-age child who has ADHD. Which of the following instructions should the nurse include?
- A. You will need to give your child the medication after meals.
- B. You will need to have your child's blood glucose level checked monthly.
- C. You should not give your child the medication on weekends.
- D. You should give your child's last daily dose of the medication before 6 o'clock in the evening.
Correct Answer: D
Rationale: Methylphenidate (Ritalin) is a medication used to treat attention-deficit hyperactivity disorder (ADHD). It is not necessary to give the medication after meals. The medication can be taken with or without food. However, some people find that taking it with food can help prevent stomach upset. Regular blood glucose level checks are not typically required when a child is taking methylphenidate. This medication does not have a significant impact on blood sugar levels. It is not generally recommended to skip doses of methylphenidate on weekends. Consistent medication administration is important for managing ADHD symptoms. However, the prescribing doctor may sometimes recommend a 'drug holiday' or break from the medication. This should only be done under the guidance of a healthcare professional. This is the correct answer. Methylphenidate is a stimulant, and taking it later in the day can cause insomnia or trouble sleeping. Therefore, it is often recommended that the last dose of the medication be given before 6 o'clock in the evening to minimize sleep disturbances.
A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?
- A. Bring your infant into the clinic today to be seen.'
- B. Burp your child more frequently during feedings.'
- C. Give your infant an oral rehydrating solution.'
- D. You might want to try switching to a different formula.'
Correct Answer: A
Rationale: The symptoms described by the parent - projectile vomiting followed by hunger - could indicate a serious condition such as pyloric stenosis, which is a narrowing of the opening from the stomach to the small intestine. This condition can lead to severe dehydration and requires immediate medical attention. While burping can help to relieve gas and minor stomach discomfort, it would not address the underlying issue causing the projectile vomiting. This advice might be appropriate for a baby with simple colic or gas, but not for the symptoms described. While oral rehydrating solutions can help to replace lost fluids and electrolytes, they do not address the underlying cause of the projectile vomiting. Furthermore, if the baby is vomiting frequently, they may not be able to keep down the solution. Switching formulas can sometimes help babies who have allergies or intolerances to certain ingredients in their current formula. However, the symptoms described are not typical of a formula intolerance or allergy. Moreover, switching formulas without seeking medical advice can potentially lead to other complications.
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.
A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse's priority?
- A. Assess fluid balance.
- B. Maintain fluid therapy.
- C. Rehydrate.
- D. Introduce a regular diet.
Correct Answer: A
Rationale: Assessing fluid balance is the priority action when caring for a child with severe diarrhea. Diarrhea can lead to significant fluid and electrolyte loss, which can result in dehydration. Early recognition and treatment of dehydration are crucial to prevent further complications. While maintaining fluid therapy is an important part of managing severe diarrhea, the first step should be to assess the child's fluid balance. Rehydration is a key part of the treatment for severe diarrhea, but it should be done after assessing the child's fluid balance. Introducing a regular diet is usually done after the acute phase of diarrhea has resolved and the child's fluid balance has been restored.
A nurse in an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler?
- A. Activated charcoal
- B. A chelating agent
- C. Acetylcysteine
- D. Digoxin immune FAB
Correct Answer: A
Rationale: Activated charcoal is often used in cases of drug overdose or poisoning, including aspirin ingestion. It works by binding to the drug or toxin in the stomach, preventing it from being absorbed into the body. This makes activated charcoal an effective treatment for aspirin overdose in a toddler. A chelating agent is a substance that can bind to heavy metals in the body, helping to remove them. While useful in cases of heavy metal poisoning, it would not be the first choice for an aspirin overdose. Acetylcysteine is an antidote for acetaminophen (Tylenol) overdose, not aspirin. It works by replenishing glutathione, a substance that helps to detoxify the liver. Digoxin immune FAB is used to treat digoxin toxicity. Digoxin is a medication used to treat heart conditions, and it is not related to aspirin.