Nokea
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.
You may also like to solve these questions
Which client on an acute care pediatric unit requires the nurse's immediate attention?
- A. An 18-month-old client who had a cleft palate repair and is crying in pain.
- B. A 12-year-old client who had an appendectomy and refuses to ambulate.
- C. An 8-year-old client who had a tonsillectomy and is swallowing frequently.
- D. A 15-year-old client who has an IV infusion and reports pain at the insertion site.
Correct Answer: C
Rationale: While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient's health. A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient's health. Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention. While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient's health.
A nurse is collecting data from a child who has muscular dystrophy. Which of the following findings should the nurse expect? (Select all that Apply)
- A. Spinal defect and sac-like protrusion
- B. Muscular weakness in lower extremities
- C. Kyphosis of the lower spine
- D. Purposeless, involuntary, abnormal movements
- E. Unsteady waddling gait
Correct Answer: B,C,E
Rationale: Choice A rationale: Spinal defects and sac-like protrusions are not typically associated with muscular dystrophy. They are more commonly seen in conditions like spina bifida. Choice B rationale: Muscular weakness in the lower extremities is a common symptom of muscular dystrophy. This is due to the progressive degeneration of muscle fibers, which leads to weakness and loss of muscle mass. Choice C rationale: Kyphosis of the lower spine can be a complication of muscular dystrophy. As the muscles supporting the spine weaken, the spine can curve abnormally, leading to kyphosis. Choice D rationale: Purposeless, involuntary, abnormal movements are not typically associated with muscular dystrophy. These symptoms are more commonly seen in neurological conditions like Huntington's disease or certain types of cerebral palsy. Choice E rationale: An unsteady waddling gait is often seen in individuals with muscular dystrophy. This is due to the progressive weakness and loss of muscle mass in the lower extremities.
A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?
- A. I will test my blood sugar before meals and at bedtime.'
- B. I should not take my regular insulin when I am sick.'
- C. I will rotate injection sites within my abdominal area.'
- D. I should eat a snack before I play soccer.'
Correct Answer: B
Rationale: Regular blood sugar testing is crucial for managing type 1 diabetes. It helps the child and their caregivers monitor the child's blood sugar levels and make necessary adjustments to their insulin doses or diet. This statement indicates a need for additional teaching. Even when sick, it's important for individuals with type 1 diabetes to continue taking their insulin. Illness often causes blood sugar levels to rise, so insulin is still needed. Rotating injection sites can help prevent skin problems, such as lipodystrophy (a lump under the skin caused by the accumulation of extra fat at the site of many subcutaneous injections of insulin). Therefore, this is a correct practice. Physical activity can lower blood sugar levels. Eating a snack before physical activities like playing soccer can help prevent hypoglycemia (low blood sugar). This is a correct understanding of managing physical activity with type 1 diabetes.
Which statement from a parent of a 1-month-old infant undergoing initial surgery for Hirschsprung's disease indicates understanding of the surgery's goal?
- A. I'm glad that the ostomy is only temporary.'
- B. The operation will straighten out the kink in the intestine.'
- C. I want to learn how to use the feeding tube as soon as possible.'
- D. I'm glad my child will have normal bowel movements now.'
Correct Answer: A
Rationale: The goal of surgery for Hirschsprung disease is to remove the diseased section of the intestine and then pull the healthy portion of this organ down to the anus. This is typically achieved through a type of surgery called a pull-through procedure. In some cases, doctors recommend ostomy surgery of the bowel followed by a pull-through procedure. During ostomy surgery, surgeons create a stoma on a child's abdomen and connect the stoma to the large or small intestine. After ostomy surgery, waste will leave the child's body through the stoma. The stoma is usually temporary. In most cases, surgeons can later close the stoma and connect the healthy part of the intestine to the anus. Waste will move through the intestines, and stool will pass through the anus again. Therefore, the statement 'I'm glad that the ostomy is only temporary' indicates understanding of the surgery's goal. The operation for Hirschsprung's disease does not involve straightening out a kink in the intestine. Instead, it involves removing the part of the large intestine that is missing nerve cells and then connecting the healthy part of the large intestine to the anus. The use of a feeding tube is not typically associated with the initial surgery for Hirschsprung's disease. The surgery involves removing the diseased section of the intestine and then pulling the healthy portion of this organ down to the anus. While the ultimate goal of the surgery is to enable normal bowel movements, it is important to note that about half of children may have ongoing problems after surgery. These problems may include constipation and, in some cases, other symptoms of intestinal obstruction, such as a swollen abdomen or vomiting.
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.