Nokea
The nurse identifies a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure for a school-age child scheduled for a tonsillectomy. Which of the following is an expected outcome for this nursing diagnosis?
- A. The child is able to tell about the surgery and recovery.
- B. The child remains on nothing-by-mouth (NPO) status for the designated preoperative period.
- C. The child and family demonstrate an understanding of the procedure.
- D. The child knows the parents will not leave.
Correct Answer: B
Rationale: The most appropriate outcome for a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure should be that the child remains NPO for the designated period of time before surgery, thereby minimizing the risk of aspiration during the surgery. Ability to tell about the surgery and demonstrating an understanding of the procedure are appropriate outcomes for a nursing diagnosis of Deficient knowledge. Knowing that the parents will not leave is associated with a nursing diagnosis of Anxiety or Fear related to separation from support systems or an unfamiliar environment.
You may also like to solve these questions
When obtaining the nursing history from the mother of an infant with suspected intussusception, which of the following questions would be most helpful?
- A. What do the stools look like?
- B. When was the last time your child urinated?
- C. Is your child eating normally?
- D. Has your child had any episodes of vomiting?
Correct Answer: A
Rationale: Stool appearance (e.g., currant jelly stools) is a hallmark of intussusception, aiding diagnosis.
A nurse who witnesses an accident involving an adolescent riding a motorcycle, hitting a tree, and being thrown 30 feet into a field stops to help. The adolescent reports that he is now unable to move his legs. While waiting for the emergency medical service to arrive, what should the nurse do?
- A. Flex the adolescent's knees to relieve stress on his back.
- B. Leave the adolescent as he is, staying close by.
- C. Remove the adolescent's helmet as soon as possible.
- D. Assess the adolescent for abdominal trauma.
Correct Answer: B
Rationale: Immobilizing the adolescent by leaving him undisturbed prevents further spinal cord damage until EMS arrives.
The physician orders a urinalysis for a child who has undergone surgical repair of a hypospadias. Which of the following results should the nurse report to the physician?
- A. Urine specific gravity of 1.017.
- B. Ten red blood cells per high-powered field.
- C. Twenty-five white blood cells per high-powered field.
- D. Urine pH of 6.0.
Correct Answer: C
Rationale: High WBC count indicates infection.
A mother asks the nurse if her child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following?
- A. Little is known about iron deficiency anemia and its relationship to infection.
- B. Children with iron deficiency anemia are more susceptible to infection than are other children.
- C. Children with iron deficiency anemia are less susceptible to infection than are other children.
- D. Children with iron deficiency anemia are equally as susceptible to infection as are other children.
Correct Answer: B
Rationale: Iron deficiency impairs immune function, increasing infection susceptibility. This is well-documented in pediatric care.
A three-year-old is brought into the emergency department in her mother's arms. The child's mouth is open and she is drooling and lethargic. Her mother states that she became ill suddenly within the past 2 hours. What should the nurse do first?
- A. Draw blood cultures for complete blood count.
- B. Start an intravenous line.
- C. Inspect the child's throat with a tongue blade.
- D. Maintain the child in an undisturbed, upright position.
Correct Answer: D
Rationale: The symptoms suggest possible epiglottitis, a medical emergency. Maintaining the child in an undisturbed, upright position prevents airway obstruction and is the priority action.