A preschool-age child is admitted to the hospital with acute postinfectious glomerulonephritis (APIGN). Which is the priority nursing diagnosis for this child?
- A. Risk for Injury related to hypertension.
- B. Altered Growth and Development related to chronic disease.
- C. Risk for Infection related to hypertension.
- D. Fluid Volume Excess related to decreased plasma filtration.
Correct Answer: A
Rationale: The priority nursing diagnosis for a preschool-age child with acute postinfectious glomerulonephritis (APIGN) is 'Risk for Injury related to hypertension' due to the potential complications such as hypertensive encephalopathy. Hypertension poses an immediate threat to the child's well-being, making it crucial to address the risk for injury associated with elevated blood pressure as the top priority.
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A healthcare professional is preparing to administer a vaccine to a child who has hemophilia. Which of the following actions should the healthcare professional take?
- A. Administer the vaccine subcutaneously
- B. Administer the vaccine intramuscularly
- C. Use a 1-inch needle
- D. Apply pressure to the site for 1 to 2 minutes
Correct Answer: B
Rationale: Administering the vaccine intramuscularly to a child with hemophilia is preferred to reduce the risk of bleeding. Hemophiliac individuals have a decreased ability to form blood clots, and administering vaccines intramuscularly reduces the risk of bleeding compared to subcutaneous administration. Using an appropriate needle length and applying pressure to the site post-injection are important steps, but choosing the intramuscular route is crucial in this case to minimize bleeding complications.
The healthcare provider is providing care to a child who was treated with aspirin during a viral infection. Which clinical manifestations should cause the healthcare provider concern?
- A. Nausea, vomiting, and confusion
- B. Headache, vomiting, and seizures
- C. Sore throat, moist respirations, and cough
- D. Fever, rash, and photophobia
Correct Answer: A
Rationale: The symptoms of nausea, vomiting, and confusion are concerning as they are indicative of Reye's syndrome, a rare but serious condition associated with aspirin use in children during viral illnesses. Reye's syndrome can lead to severe complications, including brain and liver damage, hence prompt recognition and management are crucial.
The age by which the child can make a tower of 9 cubes and imitates a circular stroke is
- A. 24 mo
- B. 30 mo
- C. 36 mo
- D. 42 mo
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 5-year-old boy is one of the shortest in class. His father is 6' tall and his mother 5'7'. What should the nurse tell his mother?
- A. He is expected to grow about 3 inches per year from ages 6 to 9.
- B. He is expected to grow about 2 inches per year from ages 6 to 9.
- C. He should be evaluated by an endocrinologist for growth hormone injections.
- D. His growth will be re-evaluated when he is 7 years old.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is providing discharge teaching to the parent of a child who has juvenile idiopathic arthritis. Which of the following statements should the nurse include?
- A. Encourage the child to sleep for 8 hours each night.
- B. Perform range-of-motion exercises once per week.
- C. Give your child NSAIDs on a regular schedule.
- D. Apply heat to the child's affected joints twice daily.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.