Nokea
The healthcare provider is developing the plan of care for a hospitalized child with von Willebrand disease. What priority nursing intervention should be included in this child's plan of care?
- A. Reduce exposure to infection.
- B. Eliminate contact with cold objects.
- C. Guard against bleeding injuries.
- D. Reduce contact with other children.
Correct Answer: C
Rationale: Children with von Willebrand disease have a deficiency in a clotting protein, putting them at risk of bleeding episodes. The priority nursing intervention for a child with von Willebrand disease is to guard against bleeding injuries to prevent excessive bleeding or hemorrhage. Choices A, B, and D are not the priority interventions for von Willebrand disease. While reducing exposure to infection is important for any hospitalized child, it is not the priority for von Willebrand disease. Eliminating contact with cold objects is more relevant for conditions like Raynaud's disease. Reducing contact with other children is not a specific priority related to managing von Willebrand disease.
You may also like to solve these questions
A 9-week-old infant is scheduled for cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Red blood cell count of 2.3 million/mm³
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds since birth
- D. Urine specific gravity is 1.011
Correct Answer: A
Rationale: The correct answer is A because a low red blood cell count may indicate anemia, which could pose risks during surgery. Anemia can affect oxygen delivery to tissues, impacting wound healing and overall surgical outcomes. The other options, such as white blood cell count, weight gain, and urine specific gravity, are less critical for immediate surgical considerations. White blood cell count is more related to infection risk postoperatively rather than immediate surgical risk. Weight gain reflects good overall growth but does not impact the immediate surgical situation. Urine specific gravity is more indicative of hydration status rather than immediate surgical risk.
What information should be reinforced with the parents of a school-aged child about Reye's syndrome?
- A. Vaccinate your child before the age of 7 against Reye's syndrome.
- B. Keep the child at home for 2 days after the symptoms appear.
- C. Avoid giving any medication containing aspirin during a viral illness.
- D. Do not provide any citrus juices during a bacterial or viral illness.
Correct Answer: C
Rationale: The correct answer is C: 'Avoid giving any medication containing aspirin during a viral illness.' It is crucial to advise parents to avoid giving any medication containing aspirin during a viral illness to prevent Reye's syndrome. Reye's syndrome is a rare but serious condition linked to the use of aspirin during viral illnesses in children and teenagers. Choices A, B, and D are incorrect because vaccinating against Reye's syndrome is not applicable as there is no specific vaccine for it, keeping the child at home for 2 days after symptoms appear is not a preventive measure for Reye's syndrome, and avoiding citrus juices is not directly related to the prevention of Reye's syndrome.
A school-age child with a history of type 1 diabetes mellitus is brought to the emergency department with confusion and rapid breathing. The practical nurse (PN) suspects diabetic ketoacidosis (DKA). Which initial intervention should the PN anticipate?
- A. Administer subcutaneous insulin.
- B. Give oral glucose tablets.
- C. Start intravenous fluids.
- D. Administer oxygen therapy.
Correct Answer: C
Rationale: Intravenous fluids are typically the initial intervention in diabetic ketoacidosis (DKA) to treat dehydration and stabilize the patient's condition. The fluid replacement helps correct electrolyte imbalances and improve perfusion, which are crucial in managing DKA. Insulin therapy follows after fluid resuscitation to address the underlying cause of DKA, which is the lack of insulin leading to increased ketone production. Administering subcutaneous insulin (Choice A) would be premature without first addressing the dehydration and electrolyte imbalances. Giving oral glucose tablets (Choice B) is contraindicated in DKA as the patient already has high blood glucose levels. Administering oxygen therapy (Choice D) may be necessary based on the patient's condition, but addressing dehydration with intravenous fluids is the priority intervention in DKA.
The mother of a 14-year-old who had a below-the-knee amputation for osteosarcoma tells the nurse that her child is angry and blaming her for allowing the amputation to occur. Which response is best for the nurse to provide?
- A. I will ask the HCP for a psychiatric consult for your child
- B. This type of acting out behavior is normal for adolescents
- C. It is important to focus on your child's needs at this difficult time
- D. A reaction of anger is your child's attempt to cope with this loss
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 10-year-old child is admitted with diabetic ketoacidosis (DKA). Which laboratory value should the practical nurse (PN) anticipate?
- A. Elevated blood glucose.
- B. Decreased serum ketones.
- C. Low urine glucose.
- D. High bicarbonate levels.
Correct Answer: A
Rationale: In a case of diabetic ketoacidosis (DKA), the primary feature is elevated blood glucose levels due to insulin deficiency. Additionally, ketones are increased in the blood and urine. Bicarbonate levels are usually low because of the metabolic acidosis that accompanies DKA. Therefore, the practical nurse should anticipate elevated blood glucose levels as a characteristic laboratory finding in a child admitted with DKA. Choice B is incorrect because serum ketones are increased in DKA. Choice C is incorrect because in DKA, urine glucose is typically high due to spillage of glucose into the urine. Choice D is incorrect because bicarbonate levels are usually low in DKA, not high.