Nokea
A six-month-old infant develops cardiac arrest following severe pneumonia. Which is the ideal airway opening maneuver?
- A. Jaw thrust
- B. Head tilt-chin lift to neutral position
- C. Head tilt-chin lift to sniffing position
- D. Look, Listen & Feel
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which is an appropriate action when an infant becomes apneic?
- A. Shake vigorously
- B. Roll head side to side
- C. Hold by feet upside down with head supported
- D. Gently stimulate trunk by patting or rubbing
Correct Answer: D
Rationale: When an infant becomes apneic (stops breathing), the appropriate action is to gently stimulate the trunk by patting or rubbing. This can help stimulate the infant to resume breathing. It is important to avoid any rough handling or shaking as this can cause harm to the infant. Rolling the head side to side or holding the infant by the feet upside down is not recommended in this situation and could potentially be dangerous. Gently stimulating the trunk is a safe and appropriate response to help the infant start breathing again.
Which clinical manifestation should a nurse monitor for when assessing a pediatric client diagnosed with a basilar skull fracture?
- A. Periorbital ecchymosis
- B. Subdural hematoma
- C. Protruding bone
- D. Epidural hematoma
Correct Answer: A
Rationale: Periorbital ecchymosis, also known as raccoon eyes, is a classic sign of a basilar skull fracture. It presents as bruising around the eyes due to blood collecting in the tissues. Monitoring for periorbital ecchymosis is crucial in assessing a pediatric client with a basilar skull fracture because it can indicate the presence of this serious injury.
A client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which "related-to" phrase should the nurse add?
- A. Related to bone demineralization resulting in pathologic fractures
- B. Related to exhaustion secondary to an accelerated metabolic rate
- C. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
- D. Related to tetany secondary to a decreased serum calcium level
Correct Answer: A
Rationale: Chronic hyperparathyroidism can lead to excessive bone demineralization due to increased levels of parathyroid hormone. This can weaken the bones and increase the risk for pathologic fractures. Therefore, the most appropriate "related-to" phrase to add to the nursing diagnosis of Risk for injury for a client with chronic hyperparathyroidism would be bone demineralization resulting in pathologic fractures. This accurately reflects the potential risk for injury associated with the client's condition.
A caregiver is seeking guidance from a healthcare provider concerning a child diagnosed with impetigo. Which of the following instructions should the healthcare provider include?
- A. Apply warm compresses to the affected area.
- B. Keep the child home from school until lesions are crusted over.
- C. Apply antibiotic ointment to the lesions.
- D. Cleanse the affected area with hydrogen peroxide.
Correct Answer: C
Rationale: The healthcare provider should recommend applying antibiotic ointment to the lesions to prevent the spread of infection and facilitate healing. Antibiotic ointment helps combat the bacterial infection associated with impetigo and supports the skin's recovery process. This approach aids in reducing symptoms, preventing complications, and promoting a quicker resolution of the condition.
A 3-month-old, former 29-week-premature infant has been scheduled for repair of bilateral inguinal hernias. The infant had received mechanical ventilation for the first 6 days of life and had apnea of prematurity that resolved 5 weeks ago. The infant is feeding well and gaining weight and has no requirement for supplemental oxygen. The hematocrit is 28. The HMO clerk approves the surgery on an outpatient basis. All of the following are true EXCEPT
- A. risk of postoperative apnea is increased by anemia
- B. accepted standard of care includes overnight inpatient apnea monitoring for this infant after general anesthesia because of a significant risk of postoperative apnea
- C. postponing the surgery incurs a small but real risk of incarceration, with complications that may include bowel obstruction and infarction of testes or ovaries
- D. after a spinal anesthetic, monitoring for apnea is not required, and the infant can be sent home from the postanesthetic care unit on the day of surgery
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.