Nokea
A school-age child who has cystic fibrosis
A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?
- A. Your child's diet should be high in carbohydrates & proteins with no restriction of fats.
- B. Limit your child's intake of sodium to avoid complications.
- C. A pigeon-shaped chest might become evident as the disease progresses.
- D. Administer a bronchodilator to the child after chest percussion therapy.
Correct Answer: C
Rationale: The correct answer is C: A pigeon-shaped chest might become evident as the disease progresses. In cystic fibrosis, the chest may appear pigeon-shaped due to the abnormal growth of the ribs and sternum. This is caused by chronic respiratory issues and increased work of breathing. It is important for the nurse to educate the parents about this potential physical manifestation of the disease so they can monitor their child's condition closely.
Incorrect choices:
A: Your child's diet should be high in carbohydrates & proteins with no restriction of fats - This is incorrect as children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B: Limit your child's intake of sodium to avoid complications - While monitoring sodium intake can be important for some conditions, it is not a primary concern in cystic fibrosis.
D: Administer a bronchodilator to the child after chest percussion therapy - While bronchodilators may be used in cystic fib
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A 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt
A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority?
- A. Lethargy
- B. Urine output 70 mL in 2 hr
- C. Lying flat on the unaffected side
- D. Respiratory rate 20/min
Correct Answer: A
Rationale: The correct answer is A: Lethargy. Following a ventriculoperitoneal shunt insertion, lethargy in a child could indicate increased intracranial pressure, a potentially life-threatening complication. The priority is to assess for signs of neurological deterioration promptly. Urine output (B) is important but not as urgent as assessing neurological status. Lying flat on the unaffected side (C) is not a priority; positioning can be adjusted later. Respiratory rate (D) within normal range is reassuring but not the priority in this case.
A child who is postoperative following a tonsillectomy
A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?
- A. Drooling
- B. Continuous swallowing
- C. Poor fluid intake
- D. Increased pain
Correct Answer: B
Rationale: The correct answer is B: Continuous swallowing. This is a clinical manifestation of hemorrhage post-tonsillectomy as the child may be swallowing blood. Drooling (A) is more indicative of airway obstruction. Poor fluid intake (C) is a sign of dehydration. Increased pain (D) can be expected postoperatively but is not specific to hemorrhage.
A child who has hemophilia
A nurse is reinforcing teaching about controlling a bleeding episode with a parent of a child who has hemophilia. Which of the following statements by the parent indicates a need for further teaching?
- A. I will elevate the affected area if possible.
- B. I will apply warm compresses over the site.
- C. I will have my child rest.
- D. I will promptly immobilize the involved area to relieve pain & decrease bleeding.
Correct Answer: B
Rationale: The correct answer is B because applying warm compresses can worsen bleeding in hemophilia by dilating blood vessels. Elevating the affected area helps reduce blood flow to the site, aiding in clot formation. Resting minimizes movement that could exacerbate bleeding. Promptly immobilizing the area helps reduce pain and prevent further bleeding. Therefore, the incorrect choice (B) contradicts the principles of managing bleeding in hemophilia.
A newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery
A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?
- A. Promote maternal-infant bonding
- B. Provide age-appropriate stimulation.
- C. Educate the parents about the defect.
- D. Maintain integrity of the sac.
Correct Answer: D
Rationale: The correct answer is D: Maintain integrity of the sac. This is the priority goal because the newborn with myelomeningocele is at risk for infection and further damage if the sac is not properly cared for. By ensuring the sac is clean, covered, and protected, the nurse can help prevent complications such as meningitis. Promoting maternal-infant bonding (A) is important but not the priority at this time. Providing age-appropriate stimulation (B) is not as urgent as ensuring the sac's integrity. Educating the parents about the defect (C) is crucial for long-term care but not the immediate priority.
An infant who has Tetralogy of Fallot and is easily fatigued when eating
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
- A. Overriding aorta
- B. Pulmonary stenosis
- C. Left ventricular hypertrophy
- D. Ventricular septal defect
Correct Answer: C
Rationale: The correct answer is C: Left ventricular hypertrophy is not present in Tetralogy of Fallot. In Tetralogy of Fallot, the four main defects are pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. Left ventricular hypertrophy is not part of the condition. The infant's fatigue during feeding is likely due to decreased oxygen levels in the blood caused by the pulmonary stenosis and right-to-left shunting at the ventricular septal defect. Choices A, B, and D are all components of Tetralogy of Fallot, making them incorrect options.