Nokea
Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.
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The physician orders intravenous fluid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before adding the potassium chloride to the intravenous fluid, which of the following assessments would be most important?
- A. Ability to void.
- B. Passage of stool today.
- C. Baseline electrocardiogram.
- D. Serum calcium level.
Correct Answer: A
Rationale: Ensuring the ability to void confirms renal function before administering potassium.
Which of the following nursing diagnoses would be appropriate for the nurse to identify as a priority diagnosis for an infant just admitted to the hospital with a diagnosis of gastroenteritis?
- A. Pain related to repeated episodes of vomiting.
- B. Deficient fluid volume related to excessive losses from severe diarrhea.
- C. Impaired parenting related to infant's loss of feeding pattern.
- D. Impaired urinary elimination related to increased fluid intake.
Correct Answer: B
Rationale: Fluid loss from diarrhea is the most urgent concern in gastroenteritis.
A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:
- A. Place a pillow under the child's buttocks to provide support.
- B. Remove the weight from the left leg.
- C. Assess the feet for signs of neurovascular impairment.
- D. Reposition the pulleys so the traction is looser.
Correct Answer: C
Rationale: Assessing for neurovascular impairment is critical, as pain could indicate compromised circulation or nerve function.
The nurse mentions that a group meeting for mothers of mentally retarded children is to be held soon. 'Not retarded!' the child's mother angrily blazes, 'Exceptional.' When responding to this outburst, which of the following replies by the nurse would be most appropriate?
- A. Retarded' is the commonly used and accepted term.'
- B. I'm sorry if I offended you by my thoughtless remark.'
- C. No matter what it's called, the condition is still the same, isn't it?'
- D. I'd like to hear more of your thoughts and feelings on that.'
Correct Answer: D
Rationale: Inviting the mother to share her feelings promotes therapeutic communication and addresses her emotional response sensitively.
After teaching the parents of a child with lactose intolerance about the disorder, the nurse determines that the teaching was effective when the mother describes the condition?
- A. The lack of an enzyme to break down lactose.
- B. An allergy to lactose found in milk.
- C. Inability to digest proteins completely.
- D. Inability to digest fats completely.
Correct Answer: A
Rationale: Lactose intolerance is due to lactase deficiency, causing lactose maldigestion. It is not an allergy or a protein/fat digestion issue.