Nokea
The nurse is assessing a child with sickle cell disease during a routine clinic visit. Which finding requires immediate follow-up by the nurse?
- A. Pallor of the nail beds and mucous membranes.
- B. A heart rate of 88 beats per minute.
- C. Intact and equal bilateral peripheral pulses.
- D. Normal vision and hearing reported by the parents.
Correct Answer: A
Rationale: Pallor of nail beds and mucous membranes indicates anemia or poor perfusion, a serious concern in sickle cell disease requiring immediate follow-up.
You may also like to solve these questions
After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best reflects the family's positive adjustment to this aspect of the child's disease?
- A. I try to keep him happy at all costs; otherwise, he has an asthma attack.
- B. We keep our child away from other children to help cut down on infections.
- C. Although our child's disease is serious, we try not to let it be the focus of our family.
- D. I'm afraid that when my child gets older, he won't be able to care for himself like I do.
Correct Answer: C
Rationale: The statement 'Although our child's disease is serious, we try not to let it be the focus of our family' reflects a positive adjustment, indicating the family is managing the chronic condition without letting it dominate their lives.
When developing the preoperative plan of care for an infant with Hirschsprung's disease, which of the following should the nurse include?
- A. Administering a tap water enema.
- B. Inserting a gastrostomy tube.
- C. Inserting a rectal tube.
- D. Using povidone-iodine solution to prepare the perineum.
Correct Answer: C
Rationale: A rectal tube may help relieve obstruction preoperatively in Hirschsprung's disease.
Because of the risks associated with administration of factor VIII concentrate, the nurse should teach the child's family to recognize and report which of the following?
- A. Yellowing of the skin.
- B. Constipation.
- C. Abdominal distention.
- D. Puffiness around the eyes.
Correct Answer: A
Rationale: Yellowing of the skin (jaundice) may indicate hepatitis, a risk with factor VIII. Other symptoms are less directly related to factor risks.
Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea?
- A. Moist mucous membranes.
- B. Passage of a soft, formed stool.
- C. Absence of diarrhea for a 4-hour period.
- D. Ability to tolerate intravenous fluids well.
Correct Answer: A
Rationale: Moist mucous membranes indicate adequate hydration, the goal of treatment.
A nurse is teaching the family of an 8-year-old boy with acute lymphocytic leukemia about appropriate activities. Which of the following activities should the nurse recommend?
- A. Home schooling.
- B. Restriction from participating in athletic activities.
- C. Avoiding trips to the shopping mall.
- D. Being treated as 'normal' as much as possible.
Correct Answer: D
Rationale: Normal activities promote psychological well-being in leukemia, with precautions for infection and bleeding risks.