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An infant who has developmental dysplasia of the hip (DDH)
A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Lengthened thigh on the affected side
- C. Absent plantar reflexes
- D. Asymmetric thigh folds
Correct Answer: A,D
Rationale: The correct answers are A and D. In DDH, an inwardly turned foot on the affected side (A) is expected due to hip dislocation. Asymmetric thigh folds (D) are also common as the affected thigh may appear shorter due to dislocation. Lengthened thigh (B) is incorrect as the thigh may appear shortened. Absent plantar reflexes (C) are not typical in DDH.
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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.
A child who has suspected cystic fibrosis
A nurse is reinforcing teaching about diagnostic tests with the parents of a child who has suspected cystic fibrosis. Which of the following diagnostic tests should the nurse include as the most definitive when diagnosing cystic fibrosis?
- A. Pulmonary function test
- B. Sweat chloride test
- C. Stool fat content analysis
- D. Sputum culture
Correct Answer: B
Rationale: The correct answer is B: Sweat chloride test. This test is the most definitive diagnostic tool for cystic fibrosis as it measures the concentration of chloride in sweat, which is typically elevated in individuals with the condition. The other choices are not as specific to cystic fibrosis. A pulmonary function test (A) evaluates lung function but does not specifically diagnose cystic fibrosis. Stool fat content analysis (C) is used to assess fat malabsorption but does not confirm cystic fibrosis. Sputum culture (D) is used to identify respiratory infections but is not specific to cystic fibrosis.
An 8-month-old child who starts to cry when his parents leave
A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents?
- A. At this age you should expect your child to be upset when you leave.
- B. Your child needs to rest.
- C. will notify the provider of his behavior.
- D. Your child is responding to an overstimulating environment.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: At 8 months old, infants develop separation anxiety, causing distress when parents leave. Acknowledging this is crucial for parents to understand normal child development. Choice B is irrelevant as the child's emotional needs should be addressed, not just physical rest. Choice C is unnecessary unless the behavior persists or causes concern. Choice D is incorrect as the child's crying is likely due to separation anxiety, not overstimulation.
A child who is to receive percussion, vibration, and postural drainage
A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first?
- A. Instruct the client to cough
- B. Perform vibration while the client exhales slowly through the nose.
- C. Percuss the upper posterior chest.
- D. Administer albuterol by nebulizer.
Correct Answer: D
Rationale: The correct answer is D: Administer albuterol by nebulizer. This should be done first to help open up the airways and facilitate the effectiveness of the subsequent treatments. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier for the child to breathe. Administering albuterol before percussion, vibration, and postural drainage will help optimize the child's lung function and overall response to the respiratory therapy.
Choice A: Instruct the client to cough - This can be done after administering albuterol to help clear any loosened secretions.
Choice B: Perform vibration while the client exhales slowly through the nose - This can be done after administering albuterol to further aid in loosening and mobilizing secretions.
Choice C: Percuss the upper posterior chest - This can be done after administering albuterol to assist in clearing secretions from the lungs.
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.