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The healthcare provider is providing postoperative care to a 7-year-old child who had surgery for appendicitis. The child is experiencing pain at the surgical site. What is the healthcare provider's priority action?
- A. Administer the prescribed pain medication
- B. Encourage the child to take deep breaths
- C. Apply a warm compress to the surgical site
- D. Reposition the child to a more comfortable position
Correct Answer: A
Rationale: Administering the prescribed pain medication is crucial to effectively manage the child's postoperative pain. Pain management is a priority to ensure the child's comfort and promote healing following surgery. Encouraging deep breaths, applying warm compresses, or repositioning the child may help, but addressing the pain with medication is the initial and most vital intervention.
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The parents of a 3-year-old boy who has Duchenne muscular dystrophy (DMD) ask, 'how can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide these parents?
- A. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
- B. The male infant had a viral infection that went unnoticed and untreated, leading to muscle damage.
- C. The lack of the protein dystrophin in the mother can impact the muscle groups of males.
- D. Damage to the spinal cord due to birth trauma from a breech vaginal birth weakens the muscles.
Correct Answer: A
Rationale: The nurse should inform the parents that Duchenne muscular dystrophy is an X-linked recessive disorder, which primarily affects male children in the family. This genetic condition is caused by a mutation in the dystrophin gene located on the X chromosome. Females are usually carriers of the gene mutation and may pass it on to their sons. Daughters of carrier mothers have a 50% chance of being carriers themselves. Understanding the genetics of DMD can help the parents make informed decisions about family planning and genetic counseling.
A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit.
- B. Administer the scheduled dose.
- C. Calculate the safe dose range.
- D. Review the serum digoxin level.
Correct Answer: B
Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.
The nurse is caring for a 15-year-old adolescent who is admitted with a diagnosis of bulimia nervosa. The adolescent's vital signs are stable, but the nurse notes that the client has dry skin and appears thin. What is the nurse's priority action?
- A. Initiate a structured eating plan for the client
- B. Establish a therapeutic relationship with the client
- C. Monitor the client's electrolyte levels
- D. Provide education on healthy eating habits
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a 10-year-old child who is scheduled for surgery to repair a fractured femur. The child's parent expresses concern about the child being afraid of the surgery. What is the nurse's best response?
- A. Children at this age are usually not afraid of surgery
- B. It's normal for your child to feel scared. Let's talk about what to expect
- C. You should talk to the surgeon about your child's fear
- D. Don't worry, your child will be fine
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What advice should be provided by the practical nurse to the mother of a school-age child with acute diarrhea and mild dehydration who is occasionally vomiting despite being given an oral rehydration solution (ORS)?
- A. Continue to give ORS frequently in small amounts.
- B. Alternate between ORS and carbonated beverages.
- C. Take the child to the hospital for intravenous fluids.
- D. Place the child NPO for the next eight to nine hours.
Correct Answer: A
Rationale: The practical nurse should advise the mother to continue providing the oral rehydration solution (ORS) frequently in small amounts. It is essential to continue ORS administration to prevent dehydration, even if the child is occasionally vomiting. Small, frequent amounts of ORS help maintain hydration levels in children with acute diarrhea and mild dehydration.