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The primary health care provider orders pulse assessments through the night for a 12-year-old child with rheumatic fever who has a daytime heart rate of 120. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by:
- A. The morning digitalis.
- B. Normal activity during waking hours.
- C. A warmer daytime environment.
- D. Normal variations in day and evening hours.
Correct Answer: B
Rationale: Elevated heart rate in rheumatic fever may be due to activity, which increases cardiac demand. Nighttime assessments help determine if the rate normalizes at rest, ruling out activity as the cause.
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A 10-year-old with leukemia is taking immunosuppressive drugs. To maintain health the nurse should instruct the child and parents to:
- A. Continue with immunizations.
- B. Not receive any live attenuated vaccines.
- C. Receive vitamin and mineral supplements.
- D. Stay away from peers.
Correct Answer: B
Rationale: Live attenuated vaccines are contraindicated in immunosuppression due to infection risk. Other options are unnecessary or overly restrictive.
A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide the treatment and
- A. Administer an aspirin-containing compound.
- B. Institute Rest, Ice, Compression, and Elevation (RICE).
- C. Begin physical therapy with active range of motion.
- D. Initiate skin traction.
Correct Answer: B
Rationale: RICE reduces swelling and bleeding in hemophilic joint bleeds. Aspirin worsens bleeding, active motion is harmful, and traction is inappropriate.
The nurse is assessing a child with leukemia who is receiving chemotherapy. Which finding indicates a potential complication requiring immediate action?
- A. A temperature of 100.4°F (38°C).
- B. A heart rate of 90 beats per minute.
- C. A platelet count of 150,000/mm³.
- D. A white blood cell count of 5,000/mm³.
Correct Answer: A
Rationale: A fever of 100.4°F in a child on chemotherapy suggests possible infection, a life-threatening complication due to immunosuppression, requiring immediate action.
Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.
The parent of a child with spastic cerebral palsy and a communication disorder tells the nurse, 'He seems so restless. I think he is in pain.' The nurse should:
- A. Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale.
- B. Assess the child using the pediatric FACES scale.
- C. Administer the pain medication which is ordered to be given as needed and assess the response.
- D. Notify the primary care provider of the change in behavior.
Correct Answer: A
Rationale: The FLACC scale is appropriate for assessing pain in children with communication disorders, as it relies on observable behaviors rather than verbal reports.