Nokea
Which of the following statements should the nurse plan to include in the discharge instructions for the child's guardian?
- A. You should cut and file your child's fingernails frequently.
- B. Cystic fibrosis
- C. You should apply a thick layer of pimecrolimus cream to your child's lesions.
- D. Your child will experience occasional flare-ups of this condition.
- E. Your child's condition is contagious when lesions are present.
- F. You can apply gloves to your child's hands.
- G. "You should apply emollients to your child's skin after bathing**
Correct Answer: A,B,D,F,G
Rationale: The correct answer includes multiple important statements for the discharge instructions.
A: Cutting and filing fingernails prevent scratching and potential skin damage.
B: Cystic fibrosis is relevant medical information for the child's care.
D: Informing about occasional flare-ups helps prepare the guardian.
F: Applying gloves prevents scratching and potential skin infection.
G: Emollients maintain skin hydration and prevent dryness. These instructions promote optimal care and management of the child's condition. Other choices are incorrect as they either provide irrelevant information (C), are not necessary for the child's care (E), or do not directly contribute to the child's well-being (B).
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Which of the following statements should the nurse make?
- A. An alarm will sound if your child has an abnormal heart rhythm.
- B. Leads will be placed on your child's back prior to the procedure.
- C. This procedure will take at least 30 minutes to complete.
Correct Answer: B
Rationale: The correct answer is B because leads are typically placed on the back before a procedure like an electrocardiogram (ECG) to monitor the heart's electrical activity. This step is crucial for obtaining accurate results. Choice A is incorrect as alarms are not typically used during ECGs. Choice C is incorrect because the duration of the procedure can vary and is not necessarily 30 minutes. Choices D, E, F, and G are blank, so they do not provide any relevant information.
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
The nurse should teach the parents to take which of the following actions during a seizure?
- A. Minimize movement of the limbs.
- B. Clear the area of hard objects.
- C. Place the child in a prone position.
- D. Insert a tongue blade between the teeth.
Correct Answer: B
Rationale: The correct answer is B: Clear the area of hard objects. This action is crucial during a seizure to prevent injury. Hard objects can cause harm if the child hits them during convulsions. Minimizing limb movement is not recommended as it may lead to further injury. Placing the child in a prone position can obstruct breathing and should be avoided. Inserting a tongue blade can also cause harm and is not recommended. Clearing the area of hard objects is the most effective way to ensure safety during a seizure.
The nurse should identify which of the following findings as a potential indicator of physical abuse?
- A. Front deciduous teeth missing
- B. Weight in 45th percentile
- C. Bruising around the wrists
- D. Abrasions on the knees
Correct Answer: C
Rationale: The correct answer is C, bruising around the wrists. This is indicative of physical abuse as it suggests grabbing or restraining. Front deciduous teeth missing (A) is more likely due to normal tooth loss. Weight in 45th percentile (B) is within a healthy range. Abrasions on the knees (D) are common in children.
Which of the following actions should the nurse take first?
- A. Obtain an x-ray of the child's neck.
- B. Administer intravenous antibiotics.
- C. Initiate droplet precautions.
- D. Place intubation equipment at the bedside.
Correct Answer: D
Rationale: The correct action for the nurse to take first is to place intubation equipment at the bedside (Choice D). This is crucial in case the child's condition deteriorates rapidly and respiratory support is needed. Placing the intubation equipment ensures immediate access to airway management, which takes precedence over other actions. Obtaining an x-ray may provide diagnostic information but is not as urgent as ensuring airway patency. Administering antibiotics and initiating droplet precautions (Choice C) are important but not the immediate priority in this scenario. Therefore, Choice D is the correct first action to ensure the child's safety and optimal care.