Nokea
During hospitalization, a 10-year-old child with acute poststreptococcal glomerulonephritis and oliguria asks for food from home. After teaching the mother and child about diet, the nurse determines that the teaching had been effective when the mother brings in which food?
- A. Pizza and cola.
- B. Hamburger and fries.
- C. Ice cream sundae.
- D. Strawberries and kiwi.
Correct Answer: D
Rationale: Low-sodium, low-protein options are best.
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Parents bring a 10-month-old boy born with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the emergency department. His symptoms include vomiting, poor feeding, lethargy, and irritability. What interventions by the nurse are appropriate? Select all that apply.
- A. Weigh the child.
- B. Listen to bowel sounds.
- C. Palpate the anterior fontanel.
- D. Obtain vital signs.
- E. Assess pitch and quality of the child's cry.
Correct Answer: C,D,E
Rationale: These symptoms suggest possible shunt malfunction or increased intracranial pressure. Palpating the anterior fontanel assesses for bulging, indicating increased pressure. Obtaining vital signs monitors for abnormalities like bradycardia or hypertension. Assessing the cry's pitch and quality can indicate neurological distress. Weighing and listening to bowel sounds are less critical in this acute context.
A 10-year-old has 5 lb of Buck's extension traction on his left leg. The nurse should assess the child for which of the following? Select all that apply.
- A. Dryness of the skin, by removing the foam wraps and boot.
- B. Alignment of the shoulder, hips, and knees.
- C. Frayed rope near pulleys.
- D. Correct amount of traction weight on fracture.
- E. Pressure on the coccyx.
Correct Answer: B,C,D,E
Rationale: The nurse should check alignment, rope condition, weight accuracy, and pressure points to ensure effective and safe traction.
A child with celiac disease is at risk for which complication if the diet is not followed?
- A. Renal failure.
- B. Intestinal lymphoma.
- C. Pulmonary fibrosis.
- D. Cardiomyopathy.
Correct Answer: B
Rationale: Untreated celiac disease increases the risk of intestinal lymphoma due to chronic inflammation. Renal, pulmonary, or cardiac complications are not directly associated.
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.
The physician is able to reduce an infant's hernia and schedules the infant for a herniorrhaphy in 2 days. The mother asks the nurse why the surgery is not performed now. Which of the following responses indicates that the nurse understands the rationale for delaying the surgery?
- A. Delaying the surgery ensures that your infant will receive the proper preoperative preparation.
- B. The infant can take nothing by mouth for at least 24 hours before the surgery.
- C. Waiting these 2 days helps to allow any edema and inflammation in the area to subside.
- D. Your infant needs to wear a truss for at least 24 hours before any surgery can be attempted.
Correct Answer: C
Rationale: Delaying surgery allows edema and inflammation to decrease, improving surgical outcomes.