Nokea
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?
- A. Monitor closely for signs of infection.
- B. Place the child with the operative side of the head up.
- C. Avoid pumping the shunt reservoir to maintain patency.
- D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.
Correct Answer: A
Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.
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What is a clinical manifestation of acetaminophen poisoning?
- A. Hyperpyrexia
- B. Hepatic involvement
- C. Severe burning pain in stomach
- D. Drooling and inability to clear secretions
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which parental statement indicates correct understanding of information presented regarding the prevention of iron deficiency anemia in infants?
- A. "We will add green leafy vegetables to our child's low-iron formula."
- B. "We will discontinue the use of vitamin C supplements by 6 months of age."
- C. "We will begin an iron-fortified infant cereal at 4 to 6 months of age."
- D. "We will introduce cow's milk by 6 months of age."
Correct Answer: C
Rationale: The correct answer is C. Introducing iron-fortified cereal between 4 to 6 months of age is a recommended practice to prevent iron deficiency anemia in infants. Iron-fortified infant cereals are a good source of iron for infants. Choices A and B are incorrect because adding green leafy vegetables to low-iron formula and discontinuing vitamin C supplements do not directly address the prevention of iron deficiency anemia. Choice D is incorrect because cow's milk should be avoided before 12 months of age as it is low in iron and can lead to intestinal blood loss, increasing the risk of iron deficiency anemia.
The nurses caring for a child are concerned about the child's frequent requests for pain medication. During a team conference, a new nurse suggests they consider administering a placebo instead of the usual pain medication to see how the child responds. The team educates the nurse on why this is not appropriate and bases the decision on what knowledge?
- A. This practice is unjustified and unethical.
- B. This practice is effective in determining whether a child's pain is real.
- C. The absence of a response to a placebo means the child's pain has an organic basis.
- D. A positive response to a placebo will not occur if the child's pain has an organic basis.
Correct Answer: A
Rationale: The correct answer is A. The use of placebos without the patient's consent is unethical and goes against the principles of beneficence and autonomy. Choice B is incorrect because using placebos does not provide reliable information about the presence or severity of the pain; it only indicates the response to the placebo itself. Choice C is wrong as the absence of a response to a placebo does not definitively mean that the child's pain has an organic basis; there could be various reasons for the lack of response. Choice D is also incorrect as individuals may have a positive response to a placebo even if their pain has a significant organic cause. Therefore, the most appropriate response is A, emphasizing the ethical concerns surrounding the use of placebos without informed consent.
When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?
- A. Change the insertion site every 24 hours.
- B. Check the insertion site frequently for signs of infiltration.
- C. Use a macrodropper to facilitate reaching the prescribed flow rate.
- D. Avoid restraining the child to prevent undue emotional stress.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During the nurse's initial assessment of a school-age child, the child reports a pain level of 6 out of 10. The child is lying quietly in bed watching television. What action should the nurse take?
- A. Reassess the child in 15 minutes to see if the pain rating has changed
- B. Administer the prescribed analgesic
- C. Do nothing since the child appears to be resting
- D. Ask the child's parents if they think the child is hurting
Correct Answer: B
Rationale: Pain management should be based on the child's report of pain, regardless of their activity level. Administering the prescribed analgesic is the appropriate action. Reassessing the child in 15 minutes without providing immediate pain relief may not be in the child's best interest. Doing nothing since the child appears to be resting may lead to inadequate pain management. Asking the child's parents if they think the child is hurting does not replace the need for direct assessment and intervention by the nurse.