Nokea
The nurse is providing care to a child with a long-leg hip spica cast. What is the priority nursing diagnosis?
- A. Risk for impaired skin integrity due to the cast and its location.
- B. Deficient knowledge related to cast care.
- C. Risk for delayed development related to immobility.
- D. Self-care deficit related to immobility.
Correct Answer: A
Rationale: The correct answer is A: Risk for impaired skin integrity due to the cast and its location. When a child has a long-leg hip spica cast, the priority nursing diagnosis is to prevent impaired skin integrity. This is because the child's mobility is restricted, and pressure from the cast can lead to skin breakdown. Option B is incorrect as while education is essential, it is not the priority when skin integrity is at risk. Option C is incorrect because while immobility can impact development, immediate skin integrity concerns take precedence. Option D is incorrect as self-care deficit, while important, is secondary to preventing skin breakdown in this scenario.
You may also like to solve these questions
A 6-year-old child with a diagnosis of juvenile idiopathic arthritis (JIA) is being discharged. What should the nurse include in the discharge teaching?
- A. Encourage participation in physical activity
- B. Provide a high-calorie diet
- C. Provide a low-sodium diet
- D. Administer intravenous fluids
Correct Answer: A
Rationale: Encouraging regular physical activity is essential in managing symptoms and improving joint function in juvenile idiopathic arthritis. Physical activity helps maintain joint mobility, muscle strength, and overall function. Providing a high-calorie diet may not be necessary unless there are specific concerns about the child's nutritional status. A low-sodium diet is not typically a priority in the management of JIA unless the child has comorbid conditions requiring sodium restriction. Administering intravenous fluids is not a standard discharge teaching for JIA unless there are specific medical indications necessitating it.
A 3-year-old child has a sudden onset of respiratory distress. The mother denies any recent illnesses or fever. You should suspect
- A. croup
- B. epiglottitis
- C. lower respiratory infection
- D. foreign body airway obstruction
Correct Answer: D
Rationale: In a 3-year-old child presenting with sudden respiratory distress without fever or recent illness, the most likely cause is a foreign body airway obstruction. Foreign body airway obstruction can lead to a sudden onset of respiratory distress as it blocks the air passage. Croup typically presents with a barking cough and stridor, often preceded by a viral illness. Epiglottitis is characterized by high fever, drooling, and a muffled voice. Lower respiratory infections usually present with symptoms such as cough, fever, and chest congestion. Therefore, in this case, the absence of recent illness or fever makes foreign body airway obstruction the most likely cause of the respiratory distress.
Which cardiac defects are associated with tetralogy of Fallot?
- A. Right ventricular hypertrophy, atrial and ventricular defects, and mitral valve stenosis
- B. Origin of the aorta from the right ventricle and of the pulmonary artery from the left ventricle
- C. Right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta
- D. Altered connection between the pulmonary artery and the aorta, right ventricular hypertrophy, and an atrial septal defect
Correct Answer: C
Rationale: Tetralogy of Fallot is characterized by a combination of four specific cardiac defects: right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta. Choice A is incorrect as it includes mitral valve stenosis, which is not typically part of tetralogy of Fallot. Choice B describes transposition of the great arteries rather than tetralogy of Fallot. Choice D includes an atrial septal defect, which is not part of the classic presentation of tetralogy of Fallot.
At 0345, you receive a call for a woman in labor. Upon arriving at the scene, you are greeted by a very anxious man who tells you that his wife is having her baby 'now.' This man escorts you into the living room where a 25-year-old woman is lying on the couch in obvious pain. After determining that delivery is not imminent, you begin transport. While en route, the mother tells you that she feels the urge to push. You assess her and see the top of the baby's head bulging from the vagina. What is your most appropriate first action?
- A. allow the head to deliver and check for the location of the cord
- B. advise your partner to stop the ambulance and assist with the delivery
- C. tell the mother to take short, quick breaths until you arrive at the hospital
- D. prepare the mother for an emergency delivery and open the obstetrics kit
Correct Answer: B
Rationale: The correct action in this scenario is to advise your partner to stop the ambulance and assist with the delivery. When the mother feels the urge to push and you see the baby's head bulging from the vagina, it indicates an imminent delivery. Stopping the ambulance allows for a safer environment for the delivery of the baby and ensures that immediate assistance can be provided to both the mother and the newborn. Allowing the head to deliver before checking for the cord (Choice A) may delay necessary interventions in case of complications. Instructing the mother to take short, quick breaths (Choice C) is not appropriate when the baby's head is already visible. Preparing for an emergency delivery and opening the obstetrics kit (Choice D) is important but should come after stopping the ambulance and assisting with the imminent birth.
A 2-year-old child is admitted to the hospital with a diagnosis of Kawasaki disease. What is the primary goal of therapy during the acute phase?
- A. Preventing coronary artery aneurysms
- B. Reducing fever
- C. Improving cardiac function
- D. Preventing dehydration
Correct Answer: A
Rationale: The primary goal of therapy during the acute phase of Kawasaki disease is to prevent coronary artery aneurysms. Kawasaki disease is characterized by systemic vasculitis and the most serious complication is the development of coronary artery aneurysms. While reducing fever and improving cardiac function are important aspects of managing Kawasaki disease, the primary focus in the acute phase is to prevent the development of coronary artery aneurysms. Preventing dehydration is also essential but not the primary goal in managing Kawasaki disease.