The nurse is assessing a 4-year-old child who is brought to the clinic for a routine checkup. The child's parent reports that the child has been more irritable and less active over the past week. The nurse notes a petechial rash on the child's trunk and extremities. What should the nurse do first?
- A. Ask the parent about recent exposure to contagious diseases
- B. Review the child's immunization record
- C. Measure the child's temperature
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The parents of a 3-month-old infant are being educated by the healthcare provider about safe sleep practices. Which statement by the parents indicates a need for further teaching?
- A. We will place our baby on their back to sleep
- B. We will use a firm mattress and avoid soft bedding
- C. We will keep our baby in our bed so we can monitor them closely
- D. We will avoid putting toys or pillows in the crib
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 6-year-old child with sickle cell anemia presents to the emergency department with severe pain in the legs and abdomen. The child is crying and states that the pain is unbearable. What is the nurse's priority action?
- A. Apply warm compresses to the painful areas
- B. Administer prescribed pain medication
- C. Encourage the child to drink fluids
- D. Monitor the child's oxygen saturation
Correct Answer: B
Rationale: In a sickle cell crisis, pain management is a priority to alleviate the child's suffering. Administering the prescribed pain medication is crucial to address the severe pain experienced by the child. Warm compresses, fluid intake, and oxygen saturation monitoring are important interventions but should follow the priority of pain management in this situation.
A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Encourage a variety of large portions of food at every meal.
- B. Allow the child to eat any food desired and tolerated.
- C. Recommend eating the food as siblings eat at home.
- D. Restrict food brought from fast food restaurants.
Correct Answer: B
Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention for a child with altered nutrition due to anorexia, nausea, and vomiting. It is crucial to prioritize maintaining adequate nutritional intake, and by allowing the child to choose foods they desire and can tolerate, the chances of improving their nutritional status increase. This approach helps in ensuring that the child receives necessary nutrients during chemotherapy, even if their appetite is affected by the treatment.
The healthcare provider is preparing a teaching plan for the parents of a 6-month-old infant with GERD. What instruction should the healthcare provider include when teaching the parents measures to promote adequate nutrition?
- A. Alternate glucose water with formula
- B. Mix the formula with rice cereal
- C. Add multivitamins with iron to the formula
- D. Use water to dilute the formula
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The infant scheduled for reduction of intussusception passes a soft-formed brown stool the day before the scheduled procedure. Which intervention should the nurse implement?
- A. Instruct the parents that the infant needs to be NPO.
- B. Notify the healthcare provider of the passage of brown stool.
- C. Obtain a stool specimen for laboratory analysis.
- D. Ask the parents about recent changes in the infant's diet.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.