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A nurse on a pediatric unit is assigned to care for a child with Reye syndrome. Which of the following is the most serious clinical manifestation for which the nurse should monitor?
- A. Anaphylaxis
- B. Cerebral edema
- C. Impaired coagulation
- D. Hypervolemia
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. In Reye syndrome, cerebral edema is the most serious manifestation due to increased intracranial pressure, potentially leading to brain damage or death. Anaphylaxis (A) is not typically associated with Reye syndrome. Impaired coagulation (C) can occur but is not as immediately life-threatening as cerebral edema. Hypervolemia (D) is a possible complication but not as critical as cerebral edema in Reye syndrome.
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A nurse is caring for a 4-year-old client with full-thickness burns. Which of the following nursing actions are essential for the care of this child? (Select all that apply.)
- A. Monitor level of consciousness
- B. Maintain intravenous fluids
- C. Document vital signs
- D. Provide a low-calorie,high carbohydrate diet
Correct Answer: A,B,C
Rationale: Level of consciousness, IV fluids, vital signs, and urinary output are critical in burn management; a high-protein, high-calorie diet is recommended instead of a low-calorie diet.
A 6-year-old child is brought to the emergency department after falling down the outdoor steps. The parent's account of the incident appears different than the neighbor's account of the incident. Upon questioning the child, the nurse should recognize which of the following as usual pattern of behavior exhibited by an abused child?
- A. The child refuses to answer questions.
- B. The child repeats the same story as the parent.
- C. The child will fabricate an obviously false story.
- D. The child tells what really happened at the time.
Correct Answer: B
Rationale: Abused children often repeat their parents' stories to avoid implicating them.
A nurse is caring for a 7-year-old child who is admitted with an asthma exacerbation.
- A. "Monitoring oxygen saturation and respiratory rate daily."'
- B. "Identification and avoidance of factors that trigger symptoms."'
- C. "Monitoring peak flow measurements regularly."'
- D. "Positioning the client upright in a position of comfort."'
Correct Answer: B
Rationale: The correct answer is B because identifying and avoiding triggers helps prevent asthma exacerbations. This proactive approach addresses the root cause of the issue, promoting long-term management. Monitoring oxygen saturation, respiratory rate, and peak flow are important but reactive measures, not addressing the underlying triggers. Positioning upright aids breathing but does not prevent exacerbations.
A nurse is providing client/patient education to the mother of an 8-year-old child diagnosed with B-hemolytic streptococci infection (strep throat). The nurse emphasizes the importance of promptly starting and completing the entire course of antibiotics.
- A. alleviate painful swallowing to avoid complications of dehydration and malnutrition'
- B. prevent sinusitis or abscess formation on the pharyngeal or peri tonsillar areas'
- C. reduce the risk of anterior cervical lymphadenopathy'
- D. eliminate organisms that might initiate acute renal failure or rheumatic fever'
Correct Answer: D
Rationale: The correct answer is D. Completing the entire course of antibiotics for strep throat is crucial to eliminate the bacteria completely. Failure to do so may lead to potential complications like acute renal failure or rheumatic fever, which are serious systemic conditions associated with untreated strep infections. This is because streptococcal infections can trigger an immune response that can attack other parts of the body if not fully eradicated.
Choice A is incorrect because while completing the antibiotics may alleviate painful swallowing, the main emphasis should be on preventing systemic complications. Choice B is incorrect as sinusitis or abscess formation are not the primary concerns with strep throat. Choice C is incorrect as reducing anterior cervical lymphadenopathy is not the primary goal of antibiotic treatment for strep throat.
In summary, completing the full course of antibiotics is crucial to eliminate the bacteria and prevent serious complications such as acute renal failure or rheumatic fever.
Which is a major difference in the clinical manifestation of adolescents with anorexia nervosa compared to bulimia?
- A. Binge eating
- B. Purging
- C. Body image distortion
- D. Decreased self esteem
Correct Answer: C
Rationale: The major difference between adolescents with anorexia nervosa and those with bulimia is body image distortion. Clients with anorexia see themselves as being overweight no matter how underweight they become. Clients with bulimia see their weight realistically but have psychological problems that manifest in an eating disorder. Both disorders may involve binge eating and purging, but body image perception is a distinguishing factor.