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A child who has spina bifida occulta
A nurse is collecting data from a child who has spina bifida occulta. Which of the following findings should the nurse expect?
- A. Flaccid paralysis of lower extremities
- B. Hip dislocation
- C. Hydrocephalus
- D. Dimple in sacral area
Correct Answer: D
Rationale: The correct answer is D: Dimple in sacral area. In spina bifida occulta, there is a small gap in the spine but no protrusion of the spinal cord or meninges. A dimple in the sacral area is a common physical finding. Flaccid paralysis of lower extremities (A) is more characteristic of myelomeningocele, not occulta. Hip dislocation (B) is not typically associated with spina bifida occulta. Hydrocephalus (C) is more commonly seen with myelomeningocele as well. The presence of a dimple in the sacral area is a key indicator of spina bifida occulta due to the incomplete closure of the spinal column.
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A child who has epiglottitis
A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take?
- A. Obtain a throat culture.
- B. Visualize the epiglottis using a tongue depressor.
- C. Provide moist air to reduce the inflammation of the epiglottis
- D. Initiate airborne precautions.
Correct Answer: C
Rationale: The correct answer is C: Provide moist air to reduce the inflammation of the epiglottis. In epiglottitis, the epiglottis is inflamed and can obstruct the airway, leading to respiratory distress. Providing moist air can help reduce inflammation and ease breathing. Option A, obtaining a throat culture, is not a priority in the acute management of epiglottitis. Option B, visualizing the epiglottis using a tongue depressor, can be dangerous and is contraindicated due to the risk of further aggravating the condition. Option D, initiating airborne precautions, is not necessary as epiglottitis is not spread through the air. Therefore, option C is the most appropriate action to prioritize in the care of a child with epiglottitis.
A child who has cystic fibrosis
A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will restrict the amount of salt in my child's meals.
- B. I will put my child in daycare to ensure that she socializes with other children.
- C. I will make sure my child washes her hands before eating.
- D. I will provide low-fat meals for my child.
Correct Answer: C
Rationale: The correct answer is C: "I will make sure my child washes her hands before eating." This statement indicates an understanding of the teaching because proper handwashing is crucial in preventing infections in individuals with cystic fibrosis who are more susceptible to respiratory infections. By washing hands before eating, the child can reduce the risk of exposure to harmful pathogens.
Choice A is incorrect because restricting salt intake is not a priority in managing cystic fibrosis. Choice B is incorrect as the focus should be on hygiene and health rather than socialization. Choice D is incorrect as children with cystic fibrosis actually require a higher calorie and fat intake.
A client who is postoperative immediately following a tonsillectomy
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the flowing snacks should the nurse offer the client?
- A. Cranberry juice
- B. Ice-cream
- C. Hot tea
- D. Italian ice
Correct Answer: B,D
Rationale: The correct snacks to offer a client post-tonsillectomy are ice-cream and Italian ice. Ice-cream is soft, cold, and soothing, helping to reduce pain and inflammation. Italian ice is also cold and can provide relief. Cranberry juice and hot tea are acidic and may irritate the surgical site. Ice-cream and Italian ice are the best choices as they are gentle on the throat and provide comfort without causing discomfort.
An infant who has respiratory syncytial virus (RSV)
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV), which of the following rooms should the nurse assign the infant?
- A. A room with a toddler who has pneumonia
- B. A private room with reverse isolation
- C. A private room with contact/droplet precautions
- D. A room with an infant who has croup
Correct Answer: C
Rationale: The correct answer is C: A private room with contact/droplet precautions. RSV is spread through respiratory secretions, so contact/droplet precautions are necessary to prevent transmission. Assigning the infant to a private room minimizes exposure to others. Choice A is incorrect as it puts the infant at risk of acquiring pneumonia. Choice B, reverse isolation, is not needed for RSV. Choice D, room with an infant with croup, is incorrect as both infants could potentially spread their respective infections to each other.
An infant with a large patent ductus arteriosus
A nurse is collecting data from an infant a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Machine like murmur
- B. Chronic hypoxemia
- C. Cyanosis with crying
- D. Weak pulse
Correct Answer: A
Rationale: The correct answer is A: Machine-like murmur. A patent ductus arteriosus (PDA) is a congenital heart defect where a blood vessel called the ductus arteriosus fails to close after birth, causing abnormal blood flow. The characteristic murmur associated with PDA is described as machine-like due to its continuous and loud nature. This murmur is heard best at the upper left sternal border. Other choices are incorrect because chronic hypoxemia (B) and cyanosis with crying (C) are more commonly seen in conditions like Tetralogy of Fallot or transposition of great vessels. Weak pulse (D) may be present in conditions like coarctation of the aorta.