Nokea
The nurse is caring for a 1-month-old girl with low-set ears and severe hypotonia who was diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?
- A. Interrupted family process related to the child's diagnosis
- B. Deficient knowledge related to the genetic disorder
- C. Grieving related to the child's poor prognosis
- D. Ineffective coping related to stress from providing care
Correct Answer: C
Rationale: The correct nursing diagnosis would be 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience feelings of grief and loss when dealing with such a diagnosis. The choice 'Interrupted family process' does not directly address the emotional response to the prognosis. 'Deficient knowledge' may be a concern but does not address the emotional aspect of dealing with a poor prognosis. 'Ineffective coping related to stress from providing care' focuses more on the caregiver's ability to cope rather than the family's response to the child's condition.
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During an assessment, a nurse is examining the skin of a child with cellulitis. What would the nurse expect to find?
- A. Red, raised hair follicles
- B. Warmth at skin disruption site
- C. Papules progressing to vesicles
- D. Honey-colored exudate
Correct Answer: B
Rationale: The correct answer is B: 'Warmth at skin disruption site.' Cellulitis is characterized by localized warmth at the site of skin disruption, which indicates an infection. Choice A, 'Red, raised hair follicles,' is more typical of folliculitis. Choice C, 'Papules progressing to vesicles,' is suggestive of conditions like herpes simplex virus infections. Choice D, 'Honey-colored exudate,' is associated with impetigo, not cellulitis. When assessing cellulitis, nurses should primarily look for warmth, erythema, edema, and tenderness at the affected site.
How should you care for an alert 4-year-old child with a mild airway obstruction, who has respiratory distress, a strong cough, and normal skin color?
- A. Back blows, abdominal thrusts, transport
- B. Oxygen, avoiding agitation, transport
- C. Assisting ventilations, back blows, transport
- D. Chest thrusts, finger sweeps, transport
Correct Answer: B
Rationale: The correct approach for an alert 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color is to provide oxygen, avoid agitation, and arrange for transport. Oxygen helps support breathing, avoiding agitation prevents worsening of the obstruction, and transport ensures the child receives further medical evaluation and treatment. Choices A, C, and D involve techniques that are not recommended for a mild airway obstruction in this scenario. Back blows, abdominal thrusts, chest thrusts, and finger sweeps are interventions used for different situations and not suitable for a child with the described symptoms.
A newborn with an anorectal anomaly had an anoplasty performed. At the 2-week follow-up visit, a series of anal dilations are begun. What should the nurse recommend to the parents to help prevent the infant from becoming constipated?
- A. Use a soy formula.
- B. Breastfeed if possible.
- C. Administer a suppository nightly.
- D. Offer glucose water between feedings.
Correct Answer: B
Rationale: Breastfeeding is the best recommendation to help prevent constipation in infants. Breast milk is easily digestible and contains the right balance of nutrients, which can lead to softer stools, thus reducing the likelihood of constipation. Offering a soy formula (Choice A) may not necessarily prevent constipation as effectively as breast milk due to differences in nutrient composition. Administering a suppository nightly (Choice C) is not a routine measure for preventing constipation in infants and may not be suitable for regular use in this scenario. Offering glucose water (Choice D) between feedings is not recommended as it does not provide the necessary nutrients found in breast milk, which are essential for preventing constipation and promoting overall health in newborns.
A parent of a 2-year-old child tells a nurse at the clinic, 'Whenever I go to the store, my child has a screaming tantrum, demanding a toy or candy on the shelves. How can I deal with this situation?' What is the nurse's best response?
- A. "Attempt to distract the child by offering a toy."
- B. "Say nothing and allow the tantrum to continue until it ends."
- C. "Have a babysitter stay with the child at home until the child outgrows this behavior."
- D. "Give the child the item while in the store, and when the child loses interest, return the item to the shelf."
Correct Answer: B
Rationale: The best approach in dealing with a child's tantrum is to not give in to their demands. By allowing the tantrum to continue until it ends, the child learns that this behavior is not effective in getting what they want. Offering a distraction (Choice A) might temporarily calm the child but does not address the underlying issue of the tantrum. Leaving the child with a babysitter (Choice C) does not teach the child how to handle such situations. Giving in to the child's demands (Choice D) reinforces the tantrum behavior.
A 2-year-old child with a diagnosis of gastroesophageal reflux disease (GERD) is being discharged. What dietary instructions should the nurse provide?
- A. Avoid spicy foods
- B. Avoid gluten
- C. Avoid high-fat foods
- D. Avoid dairy products
Correct Answer: B
Rationale: The correct dietary instruction for a 2-year-old child with GERD is to avoid gluten. Gluten is a protein found in wheat, barley, and rye that can worsen GERD symptoms. Avoiding gluten can help reduce inflammation and discomfort in the esophagus. Choices A, C, and D are incorrect because spicy foods, high-fat foods, and dairy products can exacerbate GERD symptoms. Spicy foods can irritate the esophagus, high-fat foods delay stomach emptying leading to increased acid reflux, and dairy products can stimulate acid production, all of which can worsen GERD symptoms.