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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.
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A 15-year-old has been diagnosed with acute glomerulonephritis and has been in the hospital for 1 day. Which of the following findings requires immediate action?
- A. Large amount of generalized edema.
- B. Urine specific gravity of 1.030.
- C. Large amount of albumin in the urine.
- D. 24-hour output of 1,500 mL.
Correct Answer: A
Rationale: Severe edema could indicate worsening condition.
The primary health care provider orders pulse assessments through the night for a 12-year-old child with rheumatic fever who has a daytime heart rate of 120. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by:
- A. The morning digitalis.
- B. Normal activity during waking hours.
- C. A warmer daytime environment.
- D. Normal variations in day and evening hours.
Correct Answer: B
Rationale: Elevated heart rate in rheumatic fever may be due to activity, which increases cardiac demand. Nighttime assessments help determine if the rate normalizes at rest, ruling out activity as the cause.
A nurse compares a child's height and weight with standard growth charts and finds the child to be in the 50th percentile for height and in the 45th percentile for weight. The nurse interprets these findings as indicating that the child is:
- A. Average height and weight.
- B. Overweight for height.
- C. Underweight for height.
- D. Abnormal in height.
Correct Answer: A
Rationale: 50th percentile height and 45th percentile weight indicate average growth, as they are close.
A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the infant is not developing appropriately. Which findings in the infant would indicate the need for further developmental screening?
- A. Has no interest in peek-a-boo games.
- B. Does not turn front to back.
- C. Does not babble.
- D. Continues to have head lag.
Correct Answer: D
Rationale: Head lag at 4 months suggests delayed motor development, requiring further evaluation.
A 10-year old child is admitted to the hospital with complications related to chickenpox. The nurse should do which of the following to prevent the transmission of the infection to other children on the unit? Select all that apply.
- A. Place the child on contact isolation.
- B. Wear a gown, mask, and gloves before entering the room.
- C. Place the child in a room with a 10-year-old who has had chickenpox.
- D. Place the child in a negative air-flow room.
- E. Maintain isolation until lesions have disappeared.
Correct Answer: A,B,C,E
Rationale: Chickenpox requires contact and airborne precautions (gown, mask, gloves) and isolation until lesions crust. Rooming with an immune child reduces risk. Negative airflow is for diseases like tuberculosis.