Nokea
The nurse explains to the parents of a 1-year-old child admitted to the hospital in sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following?
- A. Inadequate supply of vitamin K.
- B. Poorly oxygenated blood in the tissues.
- C. The formation of abnormal red blood cells.
- D. Inadequate tissue perfusion related to infarction.
Correct Answer: D
Rationale: In sickle cell crisis, sickle-shaped red blood cells obstruct blood flow, leading to inadequate tissue perfusion and infarction, causing local tissue damage.
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When teaching the family of an older infant who has had a hip spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?
- A. It can be adjusted to a position of comfort.
- B. It is used to lift the child.
- C. It adds strength to the cast.
- D. It is necessary to turn the child.
Correct Answer: C
Rationale: The abduction stabilizer bar maintains the legs in abduction to promote hip joint stability and adds structural strength to the cast.
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.
Which of the following nursing diagnoses would be appropriate for the nurse to identify as a priority diagnosis for an infant just admitted to the hospital with a diagnosis of gastroenteritis?
- A. Pain related to repeated episodes of vomiting.
- B. Deficient fluid volume related to excessive losses from severe diarrhea.
- C. Impaired parenting related to infant's loss of feeding pattern.
- D. Impaired urinary elimination related to increased fluid intake.
Correct Answer: B
Rationale: Fluid loss from diarrhea is the most urgent concern in gastroenteritis.
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should:
- A. Give 15 mL of juice and give another 15mL in 15 minutes.
- B. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes.
- C. Give 15 g of carbohydrate and 15 g of protein.
- D. Give 15 oz of juice and retest in 15 minutes.
Correct Answer: B
Rationale: The 15-15 rule involves giving 15 g of fast-acting carbohydrate (e.g., 4 oz juice) and retesting after 15 minutes to correct hypoglycemia. Protein is not immediate, and incorrect volumes (15 mL or 15 oz) are ineffective.
When developing a teaching plan for the mother of an asthmatic child concerning measures to reduce allergic triggers, which of the following suggestions should the nurse include:
- A. Keep the humidity in the home between 50% and 60%.
- B. Have the child sleep in the bottom bunk bed.
- C. Use a scented room deodorizer to keep the room fresh.
- D. Vacuum the carpet once or twice a week.
Correct Answer: C
Rationale: Using a scented room deodorizer can irritate airways and trigger asthma symptoms. The nurse should advise against this to reduce allergic triggers, while recommending measures like dust mite control and avoiding strong odors.