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A nurse is preparing to administer an IM injection to a 3-year-old child. Which of the following statements should the nurse make?
- A. If you don't cry, you can pick out a prize.
- B. This medicine will fix you to make you feel better.
- C. You will only feel a little stick
- D. You can choose which leg you get your medicine in.
Correct Answer: D
Rationale: The correct answer is D because allowing the child to choose which leg they receive the injection in gives them a sense of control and autonomy, reducing anxiety and fear. This empowers the child and can help build trust between the nurse and the child. Choices A and B involve rewards or vague promises, which may not be effective in alleviating the child's fear. Choice C may minimize the pain but does not address the child's potential anxiety.
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The nurse is continuing to care for the child. The nurse should anticipate a prescription for pain medication.
- A. Skin traction
- B. Surgical consultation
- C. Antibiotics
- D. Pain medication
- E. Limb immobilization
- F. Bed rest
Correct Answer: B,D
Rationale: The correct answers are B and D. A surgical consultation (B) may be needed to address the underlying cause of the child's pain. Pain medication (D) is essential to provide comfort and manage the child's pain. Skin traction (A) and limb immobilization (E) are interventions for orthopedic issues, not for immediate pain relief. Antibiotics (C) are not indicated unless there is an infection. Bed rest (F) is not a proactive measure for pain management.
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Increased intracranial pressure
- C. Upper extremity hypotension
- D. Frequent nosebleeds
Correct Answer: A
Rationale: Correct Answer: A - Weak femoral pulses
Rationale: Coarctation of the aorta results in narrowing of the aorta, leading to decreased blood flow to the lower extremities. This causes weak or absent femoral pulses due to reduced blood supply. The other choices are incorrect as coarctation of the aorta typically does not directly cause increased intracranial pressure, upper extremity hypotension, or frequent nosebleeds. These symptoms are more commonly associated with other conditions such as head trauma, vascular issues, or nasal conditions.
A nurse is caring for an infant who has necrotizing enterocolitis. Which of the following findings should the nurse expect?
- A. Hypertension
- B. Rounded abdomen
- C. Vomiting
- D. Tachypnea
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Necrotizing enterocolitis (NEC) in infants commonly presents with a rounded abdomen due to abdominal distension (B). Vomiting (C) is also a common symptom associated with NEC. Tachypnea (D) may occur due to abdominal distension and sepsis. Hypertension (A) is not typically associated with NEC in infants. The other choices are not provided, but based on typical NEC symptoms, they would not be expected in a patient with this condition.
The nurse is continuing to care for the child. Complete the following sentence by using the list of options. The child is at highest risk of developing------ as evidenced bt the child's------
- A. Deep vein thrombosis
- B. Osteomyelitis
- C. Compartment syndrome
- D. Swelling
- E. Warmth and redness
- F. Paresthesia
- G. Weak pulses
Correct Answer: C,F
Rationale: The correct answer is C, Compartment syndrome, and F, Paresthesia. Compartment syndrome results from increased pressure within a closed anatomical space, leading to compromised blood flow and nerve function. Paresthesia, abnormal sensations like tingling or numbness, is an early sign of nerve compression in compartment syndrome. The combination of these symptoms indicates a critical condition requiring immediate intervention to prevent tissue damage. Choices A, B, D, and E do not align with the clinical presentation of compartment syndrome, whereas choice G, weak pulses, may be seen in severe cases but are not specific enough to be the highest risk factor in this scenario.
A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures.
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. This should be the first action as it prioritizes the safety of the child. Seizure precautions involve ensuring a safe environment, such as removing any potential hazards and providing padding to prevent injury during a seizure. Collecting blood cultures (B) and obtaining a prescription for pain medication (A) can be important but are not as urgent as ensuring the child's safety in case of a seizure. Transporting the child for a CT scan (C) is not an immediate priority unless there is a critical need.