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An infant has been diagnosed with cow's milk allergy. What are the clinical manifestations the nurse expects to assess? (Select all that apply.)
- A. Pink mucous membranes
- B. Vomiting
- C. Rhinitis
- D. Abdominal pain
Correct Answer: B
Rationale: Pink mucous membranes are not a typical clinical manifestation of cow's milk allergy. Allergies often present with symptoms affecting the gastrointestinal tract, respiratory system, skin, or a combination of these systems.
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Kimberly, age 3 years, is being admitted for about 1 week of hospitalization. Her parents tell the nurse that they are going to buy her "a lot of new toys, because she will be in the hospital." The nurse's reply should be based on an understanding of which concept?
- A. New toys make hospitalization easier.
- B. New toys are usually better than older ones for children of this age.
- C. At this age, children often need the comfort and reassurance of familiar toys from home.
- D. Buying new toys for a hospitalized child is a maladaptive way to cope with parental guilt.
Correct Answer: C
Rationale: The correct response is based on the understanding that at the age of 3, children often find comfort and reassurance in familiar toys from home. This familiarity can help them cope with the stress and unfamiliar environment of being hospitalized. Introducing new toys may not provide the same level of comfort and may even add to the child's sense of disorientation during their stay in the hospital. It is essential to prioritize the child's emotional well-being and provide them with familiar items that can offer a sense of security during their hospitalization.
The health-care provider diagnosed a child with Legg-Calve-Perthes disease. The parents expressed their concern to you that their child's leg will be amputated. How should you respond?
- A. It is too soon to determine if amputation is necessary.
- B. No amputation is necessary because the child will make a full recovery once the disease runs its course.
- C. The health-care provider is the best person to talk to you about amputation.
- D. Not all children who have the disease require amputation.
Correct Answer: D
Rationale: Legg-Calve-Perthes disease, also known as Perthes disease, is a condition where there is a temporary loss of blood supply to the hip, leading to the breakdown of the hip joint. While in severe cases amputation may be considered as a treatment option, it is important to reassure the parents that not all children with Legg-Calve-Perthes disease require amputation. The course of treatment will depend on the severity of the condition and the individual child's response to different therapies. Therefore, it is crucial to emphasize that amputation is not the automatic outcome for all cases of Legg-Calve-Perthes disease. Encouraging the parents to discuss their concerns with the healthcare provider can provide more specific information and guidance tailored to their child's condition.
When should the nurse expect jaundice to be present in a newborn with hemolytic disease?
- A. At birth
- B. During first 24 hours after birth
- C. 24 to 48 hours after birth
- D. 48 to 72 hours after birth
Correct Answer: D
Rationale: In a newborn with hemolytic disease, jaundice typically appears 48 to 72 hours after birth due to the accumulation of bilirubin in the baby's blood. This condition is known as hyperbilirubinemia, which occurs when the liver is still immature and unable to effectively process bilirubin. The breakdown of red blood cells in hemolytic disease leads to an increased production of bilirubin, resulting in jaundice. It is important for healthcare providers to monitor the newborn closely during this time period to ensure appropriate management of the jaundice.
A patient is hemorrhaging from multiple trauma sites. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
- A. Hypertension
- B. Tachycardia
- C. Oliguria
- D. Tachypnea
Correct Answer: A
Rationale: In a patient experiencing hemorrhage from multiple trauma sites leading to hypovolemia, compensatory mechanisms typically include an increase in heart rate (tachycardia), a decrease in urine output (oliguria), and an increase in respiratory rate (tachypnea). These mechanisms are the body's way of trying to maintain vital organ perfusion in the setting of decreased blood volume. However, hypertension is not typically seen in the setting of hypovolemia. In fact, blood pressure tends to decrease as a result of reduced circulating volume.
The nurse is using calipers to measure skinfold thickness over the triceps muscle in a school- age child. What is the purpose of doing this?
- A. To measure body fat
- B. To measure muscle mass
- C. To determine arm circumference
- D. To determine accuracy of weight measurement
Correct Answer: A
Rationale: Skinfold thickness measurements using calipers are commonly used in assessing body composition, specifically to estimate body fat percentage. By measuring skinfold thickness over the triceps muscle in combination with measurements from other sites on the body, healthcare professionals can estimate the amount of subcutaneous fat present. This information is valuable in evaluating an individual's overall body composition and health status. The triceps skinfold measurement is a commonly included site in body fat calculations, especially in school-age children, where it can provide insights into growth and development.