Nokea
The nurse is continuing to care for the child. The nurse should anticipate a prescription for pain medication.
- A. Skin traction
- B. Surgical consultation
- C. Antibiotics
- D. Pain medication
- E. Limb immobilization
- F. Bed rest
Correct Answer: B,D
Rationale: The correct answers are B and D. A surgical consultation (B) may be needed to address the underlying cause of the child's pain. Pain medication (D) is essential to provide comfort and manage the child's pain. Skin traction (A) and limb immobilization (E) are interventions for orthopedic issues, not for immediate pain relief. Antibiotics (C) are not indicated unless there is an infection. Bed rest (F) is not a proactive measure for pain management.
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A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures.
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. This should be the first action as it prioritizes the safety of the child. Seizure precautions involve ensuring a safe environment, such as removing any potential hazards and providing padding to prevent injury during a seizure. Collecting blood cultures (B) and obtaining a prescription for pain medication (A) can be important but are not as urgent as ensuring the child's safety in case of a seizure. Transporting the child for a CT scan (C) is not an immediate priority unless there is a critical need.
A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Absence of hypoglycemic episodes
- D. Cessation of nocturnal enuresis
Correct Answer: D
Rationale: The correct answer is D: Cessation of nocturnal enuresis. Desmopressin is a medication used to treat diabetes insipidus by decreasing urine output. Nocturnal enuresis is a common symptom of diabetes insipidus due to excessive urine production at night. Therefore, the cessation of nocturnal enuresis indicates that the medication is effectively reducing urine output in the child. Choices A, B, and C are unrelated to the effectiveness of desmopressin in treating diabetes insipidus. Choice A, heart rate of 140/min, is not a specific indicator of desmopressin effectiveness. Choice B, capillary refill of 3 seconds, is a measure of peripheral perfusion and not directly related to diabetes insipidus. Choice C, absence of hypoglycemic episodes, is more relevant to diabetes mellitus and not diabetes insipidus.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Steatorrhea
- B. Fever
- C. Drooling
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Fever. In bacterial pneumonia, the body's immune response leads to fever as a common manifestation due to the infection. This is because the body is trying to fight off the bacterial invasion. Steatorrhea (A) is not typically associated with bacterial pneumonia. Drooling (C) is more commonly seen in conditions affecting the mouth or throat. Tinnitus (D) is a symptom related to the ears and is not typically associated with pneumonia. Therefore, the presence of fever is the most relevant sign in a child with bacterial pneumonia.
A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?
- A. Pull the pinna of the infant's ear forward before inserting the probe.
- B. Place the tip of the thermometer under the center of the infant's axilla.
- C. Insert the probe 3.8 cm (1.5 in) into the infant's rectum.
- D. Insert the oral thermometer in front of the infant's tongue.
Correct Answer: B
Rationale: Correct Answer: B - Place the tip of the thermometer under the center of the infant's axilla.
Rationale: The axillary temperature is a common method for measuring an infant's temperature. Placing the thermometer under the center of the axilla ensures an accurate reading without causing discomfort or harm to the infant.
Incorrect Choices:
A: Pulling the pinna of the infant's ear forward before inserting the probe is not necessary for measuring temperature.
C: Inserting the probe 3.8 cm (1.5 in) into the infant's rectum is invasive and not appropriate for routine temperature measurement.
D: Inserting the oral thermometer in front of the infant's tongue is incorrect as oral thermometers are not suitable for infants due to the risk of choking.
A nurse on the pediatric unit is admitting the child from the emergency department. Complete the following sentence by using the lists of options. The nurse suspects the child is experiencing rheumatic fever. The nurse should recognize the child is at greatest risk of developing--- due to---
- A. Glomerulonephritis
- B. Pericarditis
- C. Rheumatic heart disease
- D. Streptococcal pharyngitis
- E. Recent immunizations
- F. Viral infection
Correct Answer: C,D
Rationale: The correct answers are C: Rheumatic heart disease and D: Streptococcal pharyngitis. Rheumatic fever is caused by untreated streptococcal infection. If not treated promptly, it can lead to rheumatic heart disease, a serious complication. Streptococcal pharyngitis is a common precursor to rheumatic fever. Glomerulonephritis (A) is a potential complication of streptococcal infection but not directly related to rheumatic fever. Pericarditis (B) is an inflammation of the pericardium and not directly associated with rheumatic fever. Recent immunizations (E) and viral infections (F) are not linked to the development of rheumatic fever.