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A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include?
- A. Administer pain medication 30 min before physical therapy.
- B. Allow the child to set her own schedule for care.
- C. Provide low-calorie snacks.
- D. Maintain medical asepsis during dressing changes
Correct Answer: A
Rationale: Pain management is critical for burn care, especially before activities like physical therapy that can be painful. Administering pain medication 30 minutes before therapy helps ensure the child is more comfortable and able to participate effectively in rehabilitation. This is a recommended intervention. While involving the child in decisions about their care can promote autonomy and improve adherence, the schedule for burn care and therapy should be based on medical needs and healing processes rather than the child's preference. Care schedules should be designed to optimize healing and manage pain effectively. Burn patients typically have increased nutritional needs due to the high metabolic demands of healing. High-calorie, protein-rich snacks are usually recommended to support wound healing and overall recovery, rather than low-calorie options. Maintain medical asepsis during dressing changes: For burn care, maintaining sterile technique is critical to prevent infection. Medical asepsis is generally not sufficient; sterile technique is required for dressing changes to reduce the risk of infection.
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12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be?
- A. 24 lb 6 oz
- B. 20 lb 5oz
- C. 32 lb 8 0z
- D. 16 lb 4 oz
Correct Answer: A
Rationale: The nurse should expect the 12-month-old boy to weigh approximately 24 lb 6 oz (since 0.375 lb ≈ 6 oz).
So, around 24 lbs 6 oz is a normal expected weight at 12 months for a baby born at 8 lb 2 oz.
A nurse is caring for a 4-year-old child who had an incident of bedwetting during hospitalization. The child's parents expresses concern about the incident. Which of the following responses should the nurse make?
- A. I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me.
- B. Children who are hospitalized often regress. The toileting skills will return when your child is feeling better.
- C. I will discuss your child's loss of bladder control with the provider.
- D. Why is she wetting the bed in the hospital? She must wet the bed at home.
Correct Answer: B
Rationale: I know this can be embarrassing. I have kids myself so I understand, and it doesn't bother me.' This response acknowledges the child's feelings and reassures the parents that bedwetting is a common occurrence, especially during hospitalization. It also demonstrates empathy by sharing a personal experience. However, it may not address the parents' concerns about their child's bedwetting or provide information on how to manage it. 'Children who are hospitalized often regress. The toileting skills will return when your child is feeling better.' This response provides an explanation for the bedwetting incident, reassuring the parents that it is a common response to hospitalization and will likely resolve once the child feels better. It offers support and normalization of the behavior, which can help alleviate the parents' concerns. 'I will discuss your child's loss of bladder control with the provider.' This response indicates that the nurse will address the issue with the healthcare provider, which is appropriate if further evaluation or intervention is needed. However, it may not directly address the parents' concerns or provide immediate reassurance. 'Why is she wetting the bed in the hospital? She must wet the bed at home.' This response may come across as accusatory or judgmental, which can increase parental anxiety or guilt. It does not provide reassurance or support to the parents and does not address the child's immediate needs.
A nurse is reinforcing teaching about lice with the parents of a school-age child at a well-child visit. Which of the following information should the nurse include?
- A. Lice do not survive away from the host.
- B. Washing your child's hair daily will prevent lice.
- C. Encourage your child to avoid sharing hats with other children.
- D. Lice can jump from one child to another.
Correct Answer: C
Rationale: Lice do not survive away from the host.' - This statement is incorrect. Lice can survive away from the host (human scalp) for a limited period, usually up to 1-2 days. They may be found on items such as bedding, clothing, hats, or hair accessories. Therefore, proper cleaning and disinfection of these items are essential to prevent the spread of lice. 'Washing your child's hair daily will prevent lice.' - This statement is incorrect. While maintaining good hygiene is important, washing hair daily does not necessarily prevent lice infestation. Lice infestations occur through direct head-to-head contact with an infested person, not due to uncleanliness. Additionally, lice are more commonly found in clean hair rather than dirty hair. 'Encourage your child to avoid sharing hats with other children.' - This statement is correct. Sharing personal items such as hats, scarves, brushes, or hair accessories can facilitate the spread of lice from one person to another. Therefore, it's important to advise children not to share these items to reduce the risk of lice transmission. 'Lice can jump from one child to another.' - This statement is incorrect. Lice do not have the ability to jump or fly. They spread through direct contact with the hair or scalp of an infested person. However, they can crawl quickly from one person to another, especially when there is close contact, such as during play or when sharing personal items.
When assessing a child with Wilm's tumor, the nurse should keep in mind that it is most important to avoid which of the following?
- A. Measuring the child's chest circumference
- B. Palpating the child's abdomen
- C. Measuring the child's occipitofrontal circumference
- D. Placing the child in an upright position
Correct Answer: B
Rationale: Measuring the child's chest circumference: Measuring the chest circumference may not directly aid in the assessment of Wilm's tumor. While it's important for assessing respiratory conditions or monitoring growth, it's not a primary assessment for Wilm's tumor, which primarily affects the abdomen. Palpating the child's abdomen: This is an essential action in assessing for Wilm's tumor. The nurse should carefully palpate the abdomen to check for any masses, swelling, or tenderness, as these could be indicative of the tumor. Measuring the child's occipitofrontal circumference: This measurement pertains to the head circumference and is not directly related to the assessment of Wilm's tumor. While it's important for monitoring head growth and development, it's not a priority when assessing for Wilm's tumor. Placing the child in an upright position: Placing the child in an upright position may be necessary for certain assessments or procedures, but it's not directly related to assessing for Wilm's tumor. The focus should primarily be on abdominal assessment and palpation to detect any signs of the tumor.
A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will have to feed my baby formula, rather than breast milk.
- B. I should move my baby into a side-lying position during sleep.
- C. My baby's formula can be thickened with oatmeal.
- D. I will keep my baby in an upright position after feedings.
Correct Answer: D
Rationale: I will have to feed my baby formula, rather than breast milk.' - This statement indicates a misunderstanding. Breast milk is generally preferred for infants with gastroesophageal reflux (GER) because it is more easily digested and less likely to exacerbate reflux symptoms compared to formula. Breastfeeding mothers may be encouraged to continue breastfeeding, and formula-fed infants may benefit from specialized formulas designed to reduce reflux symptoms. 'I should move my baby into a side-lying position during sleep.' - This statement indicates a misunderstanding. Placing an infant in a side-lying position during sleep is not recommended due to the risk of sudden infant death syndrome (SIDS). Instead, infants with GER should be placed on their back to sleep, as recommended by safe sleep guidelines. Elevating the head of the crib or bassinet slightly may also help reduce reflux symptoms during sleep. 'My baby's formula can be thickened with oatmeal.' - This statement indicates an understanding of the teaching. Thickening formula with oatmeal or rice cereal can help reduce gastroesophageal reflux (GER) symptoms in infants by making the formula heavier and less likely to reflux back into the esophagus. However, this should only be done under the guidance of a healthcare provider to ensure proper preparation and feeding technique. 'I will keep my baby in an upright position after feedings.' - This statement indicates an understanding of the teaching. Keeping the baby in an upright position after feedings can help reduce reflux symptoms by allowing gravity to keep the stomach contents down. Parents can hold the baby upright on their shoulder or in an infant seat for a period of time after feeding to minimize reflux episodes.