Nokea
An infant is diagnosed with Hirschsprung disease. What nursing intervention is essential before surgery?
- A. Administering antibiotics
- B. Ensuring bowel rest
- C. Performing regular enemas
- D. Maintaining NPO status
Correct Answer: D
Rationale: The correct nursing intervention essential before surgery for an infant with Hirschsprung disease is maintaining NPO (nothing by mouth) status. This is important to prevent aspiration during and after the surgical procedure. Administering antibiotics (Choice A) may be necessary in some cases but is not the priority intervention before surgery. Ensuring bowel rest (Choice B) is not directly related to preparing for surgery and may not be the most critical intervention. Performing regular enemas (Choice C) is not recommended before surgery for Hirschsprung disease as it can aggravate the condition.
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The nurse is assessing a 9-year-old girl with a history of tuberculosis at age 6 years. She has been losing weight and has no appetite. The nurse suspects Addison disease based on which assessment findings?
- A. Arrested height and increased weight
- B. Thin, fragile skin and multiple bruises
- C. Hyperpigmentation and hypotension
- D. Blurred vision and enuresis
Correct Answer: C
Rationale: The correct answer is C: Hyperpigmentation and hypotension. These findings are classic signs of Addison disease, caused by adrenal insufficiency. Hyperpigmentation results from increased ACTH stimulating melanin production, and hypotension occurs due to mineralocorticoid deficiency. Choices A, B, and D are incorrect. Arrested height and increased weight are not typical of Addison disease. Thin, fragile skin and multiple bruises are seen in conditions like Cushing's syndrome, not Addison disease. Blurred vision and enuresis are not characteristic symptoms of Addison disease.
A healthcare professional is assessing a child with suspected bacterial meningitis. What is a common clinical manifestation that the healthcare professional is likely to observe?
- A. Rash
- B. Photophobia
- C. Jaundice
- D. Kernig sign
Correct Answer: D
Rationale: A common clinical manifestation of bacterial meningitis is a positive Kernig sign, indicating irritation of the meninges. Rash (Choice A) is not typically associated with bacterial meningitis. Photophobia (Choice B) can be present but is more commonly seen in viral meningitis. Jaundice (Choice C) is not a typical clinical manifestation of meningitis and is more indicative of liver dysfunction.
Based on developmental norms for a 5-year-old child, a healthcare professional decides to withhold a scheduled dose of digoxin (Lanoxin) elixir and notify the healthcare provider. Below what apical pulse did the healthcare professional withhold the medication?
- A. 60 beats/min
- B. 70 beats/min
- C. 90 beats/min
- D. 100 beats/min
Correct Answer: C
Rationale: For a 5-year-old child, an apical pulse below 90 beats/min is an indicator to withhold digoxin. Digoxin is a medication that affects the heart, and in pediatric patients, monitoring the pulse rate is crucial due to the risk of bradycardia (slow heart rate) as a potential side effect. In this case, an apical pulse of 90 beats/min or lower indicates a heart rate that may be too slow for a child of this age, warranting the withholding of digoxin and prompt notification of the healthcare provider. Choices A, B, and D are not within the critical range specified for withholding digoxin in a 5-year-old child and would not necessitate withholding the medication.
When assessing a 10-month-old infant, what developmental milestone should the nurse expect to observe?
- A. Crawling
- B. Sitting without support
- C. Standing with assistance
- D. Pulling to a stand
Correct Answer: D
Rationale: At 10 months of age, pulling to a stand is a developmental milestone that most infants can achieve. Crawling typically occurs around 6-9 months, sitting without support around 6-8 months, and standing with assistance around 7-11 months. Therefore, choices A, B, and C are not the expected developmental milestones for a 10-month-old infant.
The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?
- A. infection
- B. hypertension
- C. encephalopathy
- D. edema
Correct Answer: A
Rationale: Monitoring the temperature of a child with minimal change nephrotic syndrome is crucial to detect early signs of infection. Infection is a common complication in nephrotic syndrome, and fever can be an early indicator. Hypertension (choice B) is not typically associated with nephrotic syndrome. Encephalopathy (choice C) is a neurological complication and would present with altered mental status rather than a change in temperature. Edema (choice D) is a common symptom of nephrotic syndrome but is not typically monitored through temperature assessment.