Nokea
How can the nurse best assess that the parents demonstrate understanding of the dressing change procedure prior to discharge for their child with burns?
- A. The parents explaining the importance of using sterile technique to the nurse.
- B. The nurse observing the parents changing the dressing using appropriate technique.
- C. The parents observing the nurse changing the dressing and confirming their understanding of the procedure.
- D. The nurse allowing the parents to explain the dressing change procedure and perform it in private to boost their confidence.
Correct Answer: B
Rationale: The most effective way for the nurse to assess the parents' understanding of the dressing change procedure is by observing them as they change the dressing using the correct technique. This direct observation ensures that the parents are able to perform the task correctly and confidently before discharge. Merely verbalizing or explaining the procedure may not accurately reflect the parents' competency in performing the actual task. Choice A involves the parents explaining to the nurse, which does not directly assess their practical skills. Choice C suggests the parents observing the nurse, which does not evaluate the parents' ability to perform the task independently. Choice D focuses on boosting the parents' confidence but does not directly assess their understanding and competency in performing the dressing change.
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How should the nurse prepare the sibling of a near-drowning accident victim who wants to see his brother in the pediatric intensive care unit, considering the child was present during the accident?
- A. Have the parents explain to the child why the sibling is so sick and inform the child that this could be the last time he sees his brother.
- B. Reassure the sibling not to cry in the child's room to avoid upsetting the ill child.
- C. If death is imminent, avoid informing the child about it and minimize involvement in care to protect the child from further trauma.
- D. Cover tubes and wires with a sheet, wash off any existing blood, and prepare him for what he will see.
Correct Answer: D
Rationale: When preparing a sibling to see their brother in the pediatric intensive care unit after a near-drowning accident, it is essential to cover tubes and wires with a sheet, wash off any existing blood, and explain what the sibling will see. This approach helps the sibling understand the situation better and prepares them emotionally for the encounter, reducing potential distress and trauma. By providing information and visual preparation, the sibling can have a more controlled and less overwhelming experience when visiting their brother in the intensive care unit. Choice A is incorrect as informing the child that this could be the last time he sees his sibling may cause unnecessary distress and anxiety. Choice B is incorrect as it dismisses the sibling's emotional response, which is essential to address in a supportive manner. Choice C is incorrect as honesty and appropriate information sharing are crucial, even in difficult situations, to help the child cope effectively with the circumstances.
Kobby, who is diagnosed with diabetes mellitus type 1, displays symptoms of hypoglycemia; which of the following actions should the nurse instruct the parents to take?
- A. Give the child honey (simple sugar)
- B. Give the child milk (complex sugar)
- C. Contact the healthcare provider before doing anything
- D. Give the child nothing by mouth
Correct Answer: A
Rationale: During hypoglycemia, it is crucial to quickly raise blood glucose levels. Giving a simple sugar like honey is recommended as it can rapidly increase blood sugar levels and alleviate the symptoms of hypoglycemia in individuals with diabetes mellitus type 1. Milk, being a complex sugar, will not act as quickly as honey in raising blood sugar levels. Contacting the healthcare provider may lead to a delay in treatment, as immediate action is necessary during hypoglycemia. Withholding food or drink (choice D) is not appropriate when dealing with hypoglycemia as it can worsen the condition.
Which behavior is most indicative that a 2-year-old is experiencing the initial phase of separation anxiety because his parents cannot stay all day at the hospital with him?
- A. He withdraws from the nursing staff.
- B. He cries when his parents leave.
- C. He lies quietly in bed.
- D. He cries when his parents arrive.
Correct Answer: B
Rationale: The most indicative behavior of a 2-year-old experiencing the initial phase of separation anxiety due to parents not staying all day at the hospital is crying when his parents leave. This behavior is a common manifestation of separation anxiety in children, as they struggle with the absence of their primary attachment figures. Choices A, C, and D are less indicative because withdrawing from the nursing staff, lying quietly in bed, or crying when parents arrive do not specifically demonstrate the distress caused by separation from parents, which is the hallmark of separation anxiety in children.
A child was brought to the emergency department with complaints of nausea, vomiting, and fruity-scented breath. The resident on duty diagnosed the child with diabetic ketoacidosis. Which of the following should the nurse expect to administer?
- A. Potassium chloride IV infusion.
- B. Dextrose 5% IV infusion.
- C. Ringer's Lactate.
- D. Normal saline IV infusion
Correct Answer: D
Rationale: In diabetic ketoacidosis (DKA), there is a state of dehydration and electrolyte imbalance. Normal saline is the initial fluid of choice to help restore intravascular volume and improve electrolyte balance. It also helps to correct acidosis. Potassium chloride IV infusion is commonly added to the treatment regimen once kidney function is confirmed to prevent hypokalemia. Dextrose 5% IV infusion is not the first-line treatment for DKA as it can worsen hyperglycemia. Ringer's Lactate is not typically used as the initial fluid for managing DKA as it contains potassium and could worsen hyperkalemia.
A healthcare provider is educating a new mother on discharge. They told the mother to look for the following danger signs.
- A. Poor Feeding
- B. High Temperature
- C. Convulsions
- D. All of the Above
Correct Answer: D
Rationale: It is crucial for new mothers to be aware of potential danger signs after discharge. Poor feeding, high temperature, and convulsions are all critical symptoms that should prompt immediate medical attention. Poor feeding may indicate issues with feeding or underlying health problems. High temperature could be a sign of infection or illness. Convulsions are a serious symptom that could indicate neurological problems or other medical emergencies. By being vigilant and recognizing these signs early, the mother can help ensure the well-being of her newborn. Therefore, the correct answer is 'All of the Above' as all these signs require prompt medical attention to ensure the baby's health and safety.