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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.
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A nurse is gathering information from a 1-year-old child who has been diagnosed with Wilms' tumor. Which of the following symptoms should the nurse anticipate?
- A. Jaundice
- B. Abdominal mass
- C. Swollen joints
- D. Diarrhea
Correct Answer: B
Rationale: Jaundice, a yellowing of the skin and eyes, is not typically a symptom of Wilms' tumor. It is more commonly associated with conditions that cause liver dysfunction. An abdominal mass is one of the most common symptoms of Wilms' tumor. Parents or healthcare providers may feel a lump or swelling in the child's abdomen. Swollen joints are not a typical symptom of Wilms' tumor. They are more commonly associated with conditions that affect the joints, such as juvenile arthritis. Diarrhea is not a typical symptom of Wilms' tumor. It is more commonly a symptom of gastrointestinal illnesses.
A nurse is collecting data from a child and notes the presence of bruises on her arms and legs. Which of the following actions should the nurse take first?
- A. Tell the child what will happen to her when the abuse is reported.
- B. Request a social services referral.
- C. Report the suspected abuse to the authorities.
- D. Obtain a detailed history.
Correct Answer: D
Rationale: Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities. Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse. Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities. When a nurse notes the presence of bruises on a child's arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.
A nurse is collecting data from an infant who has otitis media. Which of the following findings should the nurse expect?
- A. Bluish-green discharge from the ear canal
- B. Erythema and edema of the affected auricle
- C. Increase in appetite
- D. Tugging on the affected ear lobe
Correct Answer: D
Rationale: Bluish-green discharge from the ear canal is not a typical finding in otitis media. This could suggest a different condition, such as an external ear infection or a ruptured eardrum. Erythema and edema of the affected auricle (outer part of the ear) are not typical findings in otitis media. These symptoms are more commonly associated with conditions affecting the external ear, such as otitis externa. An increase in appetite is not typically associated with otitis media. In fact, children with otitis media may have a decreased appetite due to discomfort or pain while swallowing. Tugging on the affected ear lobe is a common sign of otitis media in infants and young children. This is often due to the pain and discomfort caused by the infection.
What symptoms should a nurse expect in a 6-week-old infant admitted for evaluation of suspected pyloric stenosis?
- A. Projectile vomiting.
- B. Effortless regurgitation.
- C. Metabolic acidosis.
- D. Distended abdomen.
Correct Answer: A
Rationale: Projectile vomiting is a common symptom in infants with pyloric stenosis. This is due to the narrowing of the pylorus, the muscular valve at the bottom of the stomach, which prevents breast milk or formula from passing through to the small intestine. Effortless regurgitation is not typically associated with pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. Metabolic acidosis is not a typical symptom of pyloric stenosis. The hallmark symptom of pyloric stenosis is projectile vomiting. While a distended abdomen can occur in some cases of pyloric stenosis, it is not the most common symptom. The hallmark symptom of pyloric stenosis is projectile vomiting.
A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)
- A. Smooth the rough edges of the cast to maintain skin integrity
- B. Wear sterile gloves when touching or removing the cast
- C. Monitor capillary refill and color of nail beds of the left-hand
- D. Monitor for signs of pain
- E. Assess for numbness, tingling, or decreased sensation of the left hand.
Correct Answer: A,C,D,E
Rationale: Choice A rationale: Smoothing the rough edges of the cast can help maintain skin integrity and prevent skin irritation or injury. Choice C rationale: Monitoring capillary refill and color of nail beds of the left hand is important to assess the circulation to the hand and ensure that the cast is not too tight. Choice D rationale: Monitoring for signs of pain can help detect complications such as compartment syndrome, which is a serious condition that can occur if pressure within the muscles builds to dangerous levels. Choice E rationale: Assessing for numbness, tingling, or decreased sensation of the left hand is important as these can be signs of nerve damage or compression. Choice B rationale: Wearing sterile gloves when touching or removing the cast is not typically necessary. The outside of a cast is not a sterile environment, and healthcare providers do not usually wear sterile gloves when handling it.