Nokea
After a discussion with the health care provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?
- A. The diameter of the aorta is enlarged.
- B. The wall between the right and left ventricles is open.
- C. It is a narrowing of the entrance to the pulmonary artery.
- D. It is a connection between the pulmonary artery and the aorta.
Correct Answer: D
Rationale: The correct answer is D: 'It is a connection between the pulmonary artery and the aorta.' Patent ductus arteriosus (PDA) is an abnormal connection between the pulmonary artery and the aorta, which normally closes after birth. Choices A, B, and C describe different cardiac conditions and do not accurately define PDA. Choice A is incorrect because PDA does not involve the diameter of the aorta being enlarged. Choice B is incorrect because PDA does not involve the wall between the right and left ventricles being open. Choice C is incorrect because PDA is not a narrowing of the entrance to the pulmonary artery.
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A child with a diagnosis of bronchiolitis is admitted to the hospital. What is the most important nursing intervention?
- A. Administering bronchodilators
- B. Providing respiratory therapy
- C. Monitoring oxygen saturation
- D. Encouraging fluid intake
Correct Answer: B
Rationale: The most important nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention helps to maintain airway patency and improve breathing, which are crucial in managing bronchiolitis. Administering bronchodilators (Choice A) may be a part of the treatment plan but is not the most important intervention. Monitoring oxygen saturation (Choice C) is important but falls secondary to providing direct respiratory support. Encouraging fluid intake (Choice D) is also essential but does not address the immediate respiratory needs of the child with bronchiolitis.
When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include?
- A. They may occur in minor illnesses.
- B. The cause is usually readily identified.
- C. They usually do not occur during the toddler years.
- D. The frequency of occurrence is greater in females than males.
Correct Answer: A
Rationale: The correct answer is A: 'They may occur in minor illnesses.' Febrile seizures can occur even in minor illnesses, particularly in young children, and are often triggered by a rapid increase in body temperature. Choice B is incorrect because the cause of febrile seizures is not always readily identified. Choice C is incorrect as febrile seizures commonly occur in children between the ages of 6 months to 5 years, which includes the toddler years. Choice D is incorrect as febrile seizures are slightly more common in males than females.
An 8-year-old child diagnosed with meningitis is to undergo a lumbar puncture. What should the nurse explain is the purpose of this procedure?
- A. To measure the pressure of cerebrospinal fluid
- B. To obtain a sample of cerebrospinal fluid for analysis
- C. To relieve intracranial pressure
- D. To assess the presence of infection in the spinal fluid
Correct Answer: B
Rationale: A lumbar puncture is performed to obtain a sample of cerebrospinal fluid for analysis. This fluid is then examined for signs of infection, bleeding, or other abnormalities. Measuring the pressure of cerebrospinal fluid is typically done during the procedure itself, but it is not the primary purpose of the lumbar puncture. While a lumbar puncture can indirectly help relieve intracranial pressure by removing excess cerebrospinal fluid, this is not its primary purpose. Assessing the presence of infection in the spinal fluid is part of the analysis that follows the collection of the sample, making it a secondary outcome of the procedure.
A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse determine is the greatest risk for this infant?
- A. Infection
- B. Dehydration
- C. Urinary retention
- D. Intestinal obstruction
Correct Answer: A
Rationale: Infection is the greatest risk for an infant with exstrophy of the bladder due to the exposure of the bladder and surrounding tissues. The exposed bladder increases the risk of infection as it lacks the protective covering of the skin. Dehydration (Choice B) may occur but is not the greatest risk compared to infection. Urinary retention (Choice C) is less likely due to the nature of the condition. Intestinal obstruction (Choice D) is not directly associated with exstrophy of the bladder.
A 6-year-old with muscular dystrophy was recently injured falling out of bed at home. What intervention should the nurse suggest to prevent further injury?
- A. Recommend raising the bed's side rails when a caregiver is not present.
- B. Suggest a caregiver be present continuously to prevent falls from bed.
- C. Encourage the use of loose restraints while in bed.
- D. Recommend raising the bed's side rails throughout the day and night.
Correct Answer: A
Rationale: In this scenario, the most appropriate intervention to prevent further injury is to raise the bed's side rails when a caregiver is not present. This measure helps in preventing falls without the need for constant supervision. Choice B is not practical as continuous caregiver presence may not always be feasible. Choice C is unsafe as loose restraints can pose a strangulation risk. Choice D does not address the need for intervention when a caregiver is absent, potentially leading to an increased risk of falls.