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The nurse is teaching the parents of a child with developmental dysplasia of the hip (DDH) regarding the application of the Pavlik harness. Which of the following information should the nurse include in the teaching?
- A. Three diapers should be worn at all times under the harness.
- B. Harness should be removed for ten minutes every hour.
- C. Harness should always keep the legs fully adducted.
- D. Clothing should always fit loosely over the harness.
Correct Answer: D
Rationale: The correct information that the nurse should include in the teaching is that clothing should always fit loosely over the harness. This is important to prevent restriction of movement and ensure comfort for the child wearing the Pavlik harness. Tight clothing can cause discomfort, skin irritation, and interfere with the effectiveness of the harness in positioning the hip properly. Parents should be advised to choose clothing that is loose-fitting and does not put pressure on the harness or the child's skin.
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When communicating with other professionals, what is important for the nurse to do?
- A. Ask others what they want to know.
- B. Share everything known about the family.
- C. Restrict communication to clinically relevant information.
- D. Recognize that confidentiality is not possible.
Correct Answer: C
Rationale: When communicating with other professionals, it is important for the nurse to restrict communication to clinically relevant information. This ensures that only necessary and pertinent information is shared, maintaining patient confidentiality and preventing the unnecessary dissemination of sensitive details. By focusing on clinically relevant information, healthcare professionals can collaborate effectively and make well-informed decisions about patient care without compromising confidentiality or violating ethical guidelines.
The nurse is assessing a child with croup and a sore throat in the ED. The child is drooling and agitated. The nurse should know that examining the child's throat using a tongue depressor might precipitate which of the following?
- A. Profuse coughing
- B. Inspiratory stridor
- C. Complete obstruction
- D. Increased agitation
Correct Answer: C
Rationale: When assessing a child with croup who is drooling and agitated, the nurse should be aware that examining the throat using a tongue depressor can potentially precipitate a complete airway obstruction. Croup is characterized by upper airway inflammation, particularly around the larynx and trachea, leading to a barking cough, hoarseness, and respiratory distress. In a child with croup who is already showing signs of airway compromise such as drooling and agitation, any manipulation in the throat area can cause further swelling and lead to a complete obstruction of the airway. This can be a life-threatening emergency requiring immediate intervention to secure the airway and ensure adequate oxygenation. Therefore, utmost caution should be taken when performing any procedures that may exacerbate the child's respiratory distress in this situation.
A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and cyanotic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of the highest priority to the lowest priority. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).
- A. Call Jason's parents and notify them of the situation.
- B. Call Jason's family practitioner to obtain further orders for medication.
- C. Promptly administer an intramuscular dose of epinephrine. TestBankWorld.org
- D. Call 911 and wait for the emergency response personnel to arrive.
Correct Answer: c
Rationale: The highest priority intervention in this situation is 'C': Promptly administer an intramuscular dose of epinephrine. Epinephrine is The first-line treatment for anaphylaxis, which is a severe allergic reaction that can be life-threatening. Administering Epinephrine as soon as possible can help reverse The symptoms and stabilize The child.
Poor prognostic factors in Hodgkin lymphoma include all the following EXCEPT
- A. age of more than 15 year at the time of diagnosis
- B. stage IV disease
- C. manifested by positron emission tomography (PET) scan positivity
- D. presence of bulky mediastinal mass
Correct Answer: A
Rationale: Older age is generally considered a poor prognostic factor, but not necessarily worse than other listed options.
Tara is an 11-year-old girl diagnosed with type 1 diabetes mellitus (DM). She asks her attending nurse why she can't take a pill rather than shots like her grandmother does. Which of the following would be the nurse's best reply?
- A. "If your blood glucose levels are controlled, you can switch to using pills."
- B. "The pills correct fat and protein metabolism, not carbohydrate metabolism."
- C. "Your body does not make insulin, so the insulin injections help to replace it."
- D. "The pills work on the adult pancreas, you can switch when you are 18."
Correct Answer: C
Rationale: The nurse's best reply would be option C, "Your body does not make insulin, so the insulin injections help to replace it." This response directly addresses Tara's question about why she needs insulin injections instead of pills. In type 1 diabetes mellitus, the body's immune system mistakenly attacks the beta cells in the pancreas that produce insulin. As a result, individuals with type 1 DM do not produce insulin, so they require insulin injections to replace the missing hormone. Unlike type 2 diabetes where oral medications can be used to manage the condition, individuals with type 1 diabetes rely on insulin injections to regulate their blood glucose levels.