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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A 4-year-old child is admitted to the hospital with a diagnosis of epiglottitis. What is the priority nursing intervention?
- A. Administer antibiotics
- B. Provide humidified oxygen
- C. Keep the child NPO
- D. Position the child upright
Correct Answer: C
Rationale: The priority nursing intervention for a 4-year-old child admitted with epiglottitis is to keep the child NPO (nothing by mouth). This is crucial to prevent further airway compromise due to the inflamed epiglottis. Administering antibiotics may be necessary but is not the priority at this moment. Providing humidified oxygen can support oxygenation but does not address the immediate risk of airway obstruction. Positioning the child upright may help with breathing but does not address the risk of aspiration. Keeping the child NPO is essential to maintain a patent airway and prevent complications associated with epiglottitis.
A 2-year-old child with a diagnosis of hemophilia is admitted to the hospital. What should the nurse include in the care plan?
- A. Encourage participation in contact sports
- B. Use a soft toothbrush for oral care
- C. Administer nonsteroidal anti-inflammatory drugs
- D. Administer aspirin for pain
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Where should the child admitted with injuries that may be related to abuse be placed?
- A. In a private room
- B. With an older, friendly child
- C. With a child of the same age
- D. In a room near the nurses' desk
Correct Answer: D
Rationale: The correct answer is to place the child in a room near the nurses' desk. This placement allows for close monitoring and immediate intervention if needed, ensuring the safety and well-being of the child. Placing the child in a private room (Choice A) may limit visibility and monitoring. Putting the child with an older, friendly child (Choice B) or a child of the same age (Choice C) does not prioritize the necessary close monitoring and intervention that a child potentially experiencing abuse requires. Hence, placing the child in a room near the nurses' desk is the most appropriate choice in this scenario.
During a routine monthly examination, a 5-month-old infant is brought to the pediatric clinic. What assessment finding should alert the nurse to notify the health care provider immediately?
- A. Temperature of 99.5°F
- B. Blood pressure of 75/48 mm Hg
- C. Heart rate of 100 beats per minute
- D. Respiratory rate of 50 breaths per minute
Correct Answer: D
Rationale: A respiratory rate of 50 breaths per minute in a 5-month-old infant is higher than the expected range and may indicate respiratory distress. This finding is concerning and should prompt the nurse to notify the health care provider for further evaluation and intervention. A temperature of 99.5°F, blood pressure of 75/48 mm Hg, and heart rate of 100 beats per minute are within normal ranges for a 5-month-old infant. Elevated temperature may indicate a mild fever, which can be monitored. A blood pressure of 75/48 mm Hg is within the normal range for infants. A heart rate of 100 beats per minute is also within the expected range for a 5-month-old infant and does not typically require immediate notification of the health care provider.
What is the priority nursing responsibility when a 3-year-old child in a crib has a clamped jaw and is having a tonic-clonic seizure?
- A. Apply restraints.
- B. Administer oxygen.
- C. Protect the child from self-injury.
- D. Insert a plastic airway in the child's mouth.
Correct Answer: C
Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints is not recommended during a seizure as it can lead to further harm. Administering oxygen may be necessary after the seizure to support oxygenation, but it is not the priority during the seizure itself. Inserting a plastic airway is also not indicated as the jaw is clamped, and the child should not have anything placed in the mouth during a seizure. Therefore, the correct action is to ensure the child's safety by protecting them from self-injury, preventing harm from uncontrolled movements and potential falls.