Nokea
The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child?
- A. Reduce cerebral edema and lower intracranial pressure
- B. Avert hypotension and septic shock
- C. Prevent cardiac arrhythmias and heart failure
- D. Promote kidney perfusion and normal blood pressure
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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While preparing a 10-year-old with a lacerated forehead for suturing, the nurse notices both parents and a 12-year-old sibling at the child's bedside. Which instruction best supports the family's involvement?
- A. While waiting for the healthcare provider, only one visitor may stay with the child.
- B. All of you should leave while the healthcare provider sutures the child's forehead.
- C. It is best if the sibling goes to the waiting room until the suturing is completed.
- D. Please decide who will stay when the healthcare provider begins suturing.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take?
- A. Auscultate the lungs for respiratory pneumonia.
- B. Change to latex-free gloves when handling infant.
- C. Draw blood to analyze for streptococcal infection.
- D. Apply zinc oxide to perineum with each diaper change.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What action should the nurse take if an infant, who was born yesterday weighing 7.5 lbs (3,402 grams), weighs 7 lbs (3,175 grams) today?
- A. Inform and assure the mother that this is normal weight loss.
- B. Encourage the mother to increase the frequency of breastfeeding.
- C. After verifying the accuracy of weight, notify the healthcare provider.
- D. Monitor the stool and urine output of the neonate for the last 24 hours.
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to inform and assure the mother that this weight loss is normal. Newborns can lose up to 10% of their birth weight in the first few days after birth, which is attributed to fluid loss and adjustment to life outside the womb. This weight loss is typically regained within the first two weeks of life. It is crucial for the nurse to educate and provide reassurance to the mother about this common occurrence in newborns.
When assessing a child with HIV, which system should the nurse assess first?
- A. Assess the respiratory system.
- B. Assess the gastrointestinal system.
- C. Assess the cardiovascular system.
- D. Assess the neurological system.
Correct Answer: A
Rationale: When assessing a child with HIV, it is essential to prioritize assessing the respiratory system first. Children with HIV are more susceptible to respiratory infections and complications, such as pneumonia, due to their weakened immune system. Identifying any respiratory issues early on can help in prompt intervention and management, thus improving outcomes for the child.
A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement?
- A. Graph the daily weight for the past week.
- B. Decrease IV flow rate.
- C. Assess bilateral lung sounds.
- D. Restrict intake of oral fluids.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.