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A parent of a 2-year-old child tells a nurse at the clinic, 'Whenever I go to the store, my child has a screaming tantrum, demanding a toy or candy on the shelves. How can I deal with this situation?' What is the nurse's best response?
- A. "Attempt to distract the child by offering a toy to the child."
- B. "Say nothing and allow the tantrum to continue until it ends."
- C. "Have a babysitter stay with the child at home until the child outgrows this behavior."
- D. "Give the child the item while in the store, and when the child loses interest, return the item to the shelf."
Correct Answer: B
Rationale: The nurse's best response is to allow the tantrum to continue until it ends without giving in to the child's demands. By not rewarding the child with the desired item during a tantrum, the child learns that this behavior is not effective in getting what they want. Offering a toy to distract the child (Choice A) may reinforce the idea that tantrums lead to rewards. Leaving the child with a babysitter (Choice C) does not address the issue at hand, which is teaching the child appropriate behavior in public places. Giving the child the item temporarily (Choice D) may encourage the child to have tantrums in the future to obtain desired items.
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A health care provider orders a tap water enema for a 6-month-old infant with suspected Hirschsprung disease. What rationale causes the nurse to question the order?
- A. The result could lead to loss of necessary nutrients.
- B. It could cause a fluid and electrolyte imbalance.
- C. It could increase the fear of intrusive procedures.
- D. The result could cause shock from a sudden drop in temperature.
Correct Answer: B
Rationale: The correct answer is B. Tap water enemas can cause significant fluid and electrolyte imbalances, particularly in infants, making them unsafe for this age group. Choice A is incorrect because tap water enemas do not directly lead to loss of necessary nutrients. Choice C is incorrect as it focuses on emotional impact rather than physiological risks. Choice D is incorrect as shock from a sudden drop in temperature is not a common consequence of a tap water enema in this scenario.
During a clinical conference with a group of nursing students, the instructor is describing burn classifications. The instructor determines that the teaching has been successful when the group identifies what as characteristic of full-thickness burns?
- A. Skin that is reddened, dry, and slightly swollen
- B. Skin appearing wet with significant pain
- C. Skin with blistering and swelling
- D. Skin that is leathery and dry with some numbness
Correct Answer: D
Rationale: Full-thickness burns, also known as third-degree burns, are characterized by a leathery, dry appearance with numbness due to nerve damage. This type of burn extends through all layers of the skin, affecting nerve endings. Choice A describes characteristics of superficial partial-thickness burns, which involve the epidermis and part of the dermis. Choice B describes characteristics of superficial burns, or first-degree burns, which only affect the epidermis. Choice C describes characteristics of superficial to mid-dermal burns, also known as second-degree burns, which involve the epidermis and part of the dermis but do not extend through all skin layers. Therefore, the correct answer is D.
A 4-year-old child is admitted with a diagnosis of bacterial pneumonia. What is the priority nursing intervention?
- A. Administering antipyretics
- B. Administering antibiotics
- C. Monitoring fluid intake
- D. Providing nutritional support
Correct Answer: B
Rationale: The priority nursing intervention in a 4-year-old child admitted with bacterial pneumonia is administering antibiotics. Antibiotics are crucial for treating the infection and preventing potential complications. Administering antipyretics (Choice A) may help reduce fever, but addressing the underlying infection with antibiotics is the priority. Monitoring fluid intake (Choice C) is important for hydration but does not take precedence over administering antibiotics. Providing nutritional support (Choice D) is essential for overall care but is not the immediate priority when managing bacterial pneumonia.
After a child returns from surgery for a tracheostomy, what is the priority nursing action?
- A. Suctioning the tracheostomy tube
- B. Changing the tracheostomy dressing
- C. Monitoring respiratory status
- D. Ensuring the tracheostomy ties are secure
Correct Answer: A
Rationale: The priority nursing action after a tracheostomy surgery is to suction the tracheostomy tube. Suctioning helps maintain a clear airway and prevent complications such as airway obstruction or respiratory distress. While monitoring respiratory status is important, suctioning takes precedence immediately post-surgery to ensure adequate air exchange. Changing the tracheostomy dressing and ensuring tracheostomy ties are secure are also essential tasks but are secondary to the critical need for airway maintenance through suctioning.
A child with a diagnosis of leukemia is receiving chemotherapy. What is the priority nursing intervention?
- A. Monitoring for signs of infection
- B. Providing nutritional support
- C. Monitoring for signs of bleeding
- D. Monitoring for signs of pain
Correct Answer: A
Rationale: The priority nursing intervention for a child with leukemia receiving chemotherapy is monitoring for signs of infection. Chemotherapy can suppress the immune system, putting the child at a higher risk of developing infections. Early detection of signs of infection is crucial to prevent serious complications and initiate timely treatment. Providing nutritional support is important for overall health but is not the priority when the child is at risk of infection. Monitoring for signs of bleeding is essential, but infection surveillance takes precedence due to the immediate threat it poses to the child's health. Monitoring for signs of pain is important for comfort but is not the priority over infection prevention and management.