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The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?
- A. “There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance.
- B. I will have my child wear an eye patch over the good eye to help strengthen the weak eye.
- C. My child will outgrow this by the time he is 2 years old and be able to see just fine.
- D. If this eye patch does not work I know we will have to do surgery to correct my child's crossed eyes.
Correct Answer: C
Rationale: There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance.': This statement demonstrates the mother's comprehension of the cause of strabismus, which can indeed result from a muscle imbalance affecting the alignment of the eyes. Understanding the cause is essential for the mother to grasp the rationale behind treatment interventions. 'I will have my child wear an eye patch over the good eye to help strengthen the weak eye.': Patching the stronger eye is a common treatment approach for strabismus to encourage the weaker eye to become stronger and improve alignment. The mother's statement indicates her awareness of this treatment modality. 'My child will outgrow this by the time he is 2 years old and be able to see just fine.': While some cases of strabismus may improve as a child grows, not all cases resolve spontaneously. This statement suggests the mother's belief in the possibility of spontaneous resolution, which may be accurate in some instances but not guaranteed for all cases of strabismus. 'If this eye patch does not work I know we will have to do surgery to correct my child's crossed eyes.': Surgery is indeed an option for correcting strabismus, especially if conservative measures like patching do not yield satisfactory results. The mother's understanding of this potential treatment escalation reflects her grasp of the condition's management plan.
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A child is diagnosed with Wilms' tumor. During assessment, the nurse in charge expects to detect:
- A. Gross hematuria
- B. Dysuria
- C. An abdominal mass
- D. Nausea and Vomiting
Correct Answer: C
Rationale: Gross hematuria: Gross hematuria refers to visible blood in the urine, which can present as pink, red, or cola-colored urine. While hematuria can be associated with various kidney conditions, including Wilms' tumor, it is not a consistent or defining symptom of this specific tumor. Additionally, because the tumor is typically confined within the kidney and does not usually invade the urinary tract, gross hematuria might not always be present. Dysuria: Dysuria is the medical term for painful or difficult urination. It is not a typical symptom of Wilms' tumor, as this tumor primarily affects the kidney and may not directly affect the urinary tract in a way that causes painful urination. An abdominal mass: This is the correct answer. Wilms' tumor often presents as a palpable abdominal mass, which may be felt during physical examination. The mass is usually firm, non-tender, and confined to one side of the abdomen. Detection of an abdominal mass should prompt further diagnostic evaluation to confirm the diagnosis and plan appropriate treatment. Nausea and vomiting: While some children with Wilms' tumor may experience nausea and vomiting, these symptoms are nonspecific and can be caused by various conditions. They are not considered characteristic or defining features of Wilms' tumor. The presence of nausea and vomiting would prompt further assessment to determine the underlying cause.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Monitor the client's hemoglobin level
- B. Restrain the client's extremities
- C. Place the client in a prone position
- D. Record the time and length of the seizure
Correct Answer: D
Rationale: Monitor the client's hemoglobin level: Monitoring the client's hemoglobin level is not relevant during a seizure. Seizures typically do not directly affect hemoglobin levels, so this action is not appropriate. Restrain the client's extremities: Restraint is generally not recommended during a seizure unless absolutely necessary for the safety of the client or others. Restraint can potentially cause injury to the client and increase agitation during the seizure. Place the client in a prone position: Placing the client in a prone (face-down) position during a seizure is not recommended. This position may increase the risk of airway obstruction and compromise the client's ability to breathe effectively. Record the time and length of the seizure: This is the correct answer. During a seizure, the nurse should prioritize ensuring the safety of the client and others. After ensuring safety, the nurse should document important details about the seizure, including the time it began and ended, as well as any observed symptoms or behaviors. This documentation can provide valuable information for the client's healthcare team and help guide future treatment decisions.
A nurse is assisting with the care of a client who has partial-thickness and full-thickness burns to his upper torso and face. Which of the following actions should the nurse take to prevent infection?
- A. Place new linen on the client's bed every other day.
- B. Change gloves between sites when providing wound care to multiple wounds.
- C. Change the dressing on infected wounds first.
- D. Monitor vital signs every 4 hr.
Correct Answer: B
Rationale: Place new linen on the client's bed every other day: While changing linen regularly is important for maintaining cleanliness and preventing infection, waiting every other day may not be sufficient for a client with burns, especially if there is wound drainage or soiling. Linens should be changed more frequently, ideally daily or as needed, to ensure cleanliness and prevent the spread of infection. Change gloves between sites when providing wound care to multiple wounds: This is a correct action. Changing gloves between sites when providing wound care helps prevent the spread of infection from one wound to another. It reduces the risk of cross-contamination and helps maintain a sterile environment during wound care procedures. Change the dressing on infected wounds first: This is incorrect. Dressings on infected wounds should be changed promptly to prevent the spread of infection. However, changing the dressing on infected wounds first may lead to contamination of other wound sites if proper precautions are not taken. It's important to follow proper infection control procedures, including changing gloves between wound sites and using aseptic technique. Monitor vital signs every 4 hr: Monitoring vital signs is important for assessing the client's overall condition, but it is not directly related to preventing infection. Vital signs may indicate signs of infection, such as fever or increased heart rate, but they do not prevent infection on their own. Other measures, such as wound care and infection control practices, are more directly related to preventing infection in clients with burns.
The nurse is providing discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicate that further teaching is necessary?
- A. I give him medication so he'll be comfortable.
- B. I check his voiding to be sure there's no problem.
- C. I check his temperature.
- D. I'll let him decide when to return to his play activities.
Correct Answer: D
Rationale: I give him medication so he'll be comfortable.' - This statement indicates that the parents are providing medication to ensure the child's comfort after the procedure, which is an appropriate action. It suggests that the parents are attentive to the child's needs postoperatively. 'I check his voiding to be sure there's no problem.' - Checking the child's voiding is important postoperatively to ensure there are no urinary retention issues or other complications related to urination. This statement reflects appropriate postoperative care and monitoring. 'I check his temperature.' - Monitoring the child's temperature is also a good practice postoperatively to watch for signs of infection or other complications. This statement indicates that the parents are attentive to signs of potential postoperative issues. 'I'll let him decide when to return to his play activities.' - This statement suggests that the parents plan to let the child decide when to resume play activities after the surgery. However, after a surgical procedure like orchiopexy, it's important for parents to follow specific guidelines provided by healthcare providers regarding activity restrictions and return to normal activities. Allowing the child to decide may not align with the recommended postoperative care plan.
12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be?
- A. 24 lb 6 oz
- B. 20 lb 5oz
- C. 32 lb 8 0z
- D. 16 lb 4 oz
Correct Answer: A
Rationale: The nurse should expect the 12-month-old boy to weigh approximately 24 lb 6 oz (since 0.375 lb ≈ 6 oz).
So, around 24 lbs 6 oz is a normal expected weight at 12 months for a baby born at 8 lb 2 oz.