Nokea
The nurse is planning the care of a hospitalized 4-year-old. The most appropriate technique the nurse can use to reduce the stress of hospitalization for this child is to:
- A. Encourage the child to discuss their feelings.
- B. Encourage peer visitation.
- C. Encourage the child to play with safe medical equipment.
- D. Read a story to the child.
Correct Answer: C
Rationale: Encouraging the child to play with safe medical equipment is the most appropriate technique to reduce stress for a hospitalized child. This technique helps familiarize the child with medical equipment in a non-threatening way, empowering them to feel more in control of the environment. Options A, B, and D may be helpful but do not directly address the child's exposure and interaction with the hospital environment, making them less effective in reducing stress in this context.
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How would you classify a child at two years of age who has fast breathing without chest indrawing or stridor when calm?
- A. Very severe disease
- B. Pneumonia
- C. No pneumonia
- D. Local infection
Correct Answer: B
Rationale: In pediatric clinical assessment, a child at two years of age with fast breathing but without chest indrawing or stridor when calm is classified as having pneumonia. Fast breathing in this context is a key symptom used in the Integrated Management of Childhood Illness (IMCI) guidelines to diagnose pneumonia in children under five years old. The absence of chest indrawing or stridor when the child is calm helps differentiate this case from other respiratory conditions, making pneumonia the likely classification. Choices A, C, and D are incorrect. 'Very severe disease' is too broad and not specific to the symptoms described. 'No pneumonia' is also incorrect as the symptoms match the presentation of pneumonia. 'Local infection' is too vague and does not specifically address the respiratory symptoms observed.
How should the nurse prepare the sibling of a near-drowning accident victim who wants to see his brother in the pediatric intensive care unit, considering the child was present during the accident?
- A. Have the parents explain to the child why the sibling is so sick and inform the child that this could be the last time he sees his brother.
- B. Reassure the sibling not to cry in the child's room to avoid upsetting the ill child.
- C. If death is imminent, avoid informing the child about it and minimize involvement in care to protect the child from further trauma.
- D. Cover tubes and wires with a sheet, wash off any existing blood, and prepare him for what he will see.
Correct Answer: D
Rationale: When preparing a sibling to see their brother in the pediatric intensive care unit after a near-drowning accident, it is essential to cover tubes and wires with a sheet, wash off any existing blood, and explain what the sibling will see. This approach helps the sibling understand the situation better and prepares them emotionally for the encounter, reducing potential distress and trauma. By providing information and visual preparation, the sibling can have a more controlled and less overwhelming experience when visiting their brother in the intensive care unit. Choice A is incorrect as informing the child that this could be the last time he sees his sibling may cause unnecessary distress and anxiety. Choice B is incorrect as it dismisses the sibling's emotional response, which is essential to address in a supportive manner. Choice C is incorrect as honesty and appropriate information sharing are crucial, even in difficult situations, to help the child cope effectively with the circumstances.
A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:
- A. Sleep Pattern Disturbance related to pain.
- B. Pain related to ear infection.
- C. Altered Family Processes related to ill child.
- D. Ineffective Thermoregulation Related to Infection
Correct Answer: B
Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.
Jaundice in children can be either pathological or physiological. Which of these will you consider as more serious?
- A. Jaundice seen within 24 hours of life
- B. Jaundice seen at the palms and soles
- C. Jaundice appearing after 24 hours of life
- D. Jaundice seen after 14 days of life
Correct Answer: A
Rationale: Jaundice seen within 24 hours of life is considered more serious in children as it can indicate pathological causes such as hemolytic disease or sepsis, which require prompt evaluation and management to prevent complications. Jaundice appearing within 24 hours of life is concerning due to the higher likelihood of severe conditions, while jaundice seen at the palms and soles is more likely due to physiological causes such as breast milk jaundice. Jaundice appearing after 24 hours or after 14 days of life may still require evaluation but is less urgent compared to jaundice within the first 24 hours.
Fred is a 12-year-old boy diagnosed with pneumococcal pneumonia. Which of the following would Nurse Nica expect to assess?
- A. Mild cough
- B. Slight fever
- C. Chest pain
- D. Bulging fontanel
Correct Answer: C
Rationale: Chest pain is a common symptom seen in patients with pneumococcal pneumonia. It can result from inflammation of the pleura or irritation of the diaphragm due to the infection. While cough and fever are also common symptoms, chest pain is particularly significant in pneumonia cases as it can be a distressing symptom for the patient and may indicate complications or severity of the infection. Bulging fontanel, on the other hand, is more indicative of conditions affecting infants and is not typically associated with pneumococcal pneumonia in a 12-year-old boy.