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What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for children with this diagnosis?
- A. Slow respirations
- B. Clubbing of fingers
- C. Decreased RBC counts
- D. Subcutaneous hemorrhages
Correct Answer: B
Rationale: Clubbing of fingers is a common manifestation in children with tetralogy of Fallot due to chronic hypoxia. Clubbing occurs as a result of long-standing decreased oxygen levels in the blood, leading to changes in the fingertips. Slow respirations (Choice A) are not typically a direct clinical manifestation of tetralogy of Fallot. While decreased RBC counts (Choice C) may occur due to chronic hypoxia, they are not a primary manifestation specific to tetralogy of Fallot. Subcutaneous hemorrhages (Choice D) are not a common clinical manifestation associated with tetralogy of Fallot.
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The nurse is caring for a boy with probable intussusception. He had diarrhea before admission, but while waiting for the administration of air pressure to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate?
- A. notify the practitioner
- B. measure abdominal girth
- C. auscultate for bowel sounds
- D. take vital signs, including blood pressure
Correct Answer: A
Rationale: The passage of a normal brown stool in a child with intussusception could indicate spontaneous reduction of the intussusception. This change in the patient's condition is significant, requiring prompt notification of the practitioner for further evaluation and management. While measuring abdominal girth (Choice B) is important for assessing abdominal distention, it is not the priority when a potential spontaneous reduction may have occurred. Auscultating for bowel sounds (Choice C) and taking vital signs, including blood pressure (Choice D), are routine nursing assessments but do not address the immediate need to inform the practitioner of a possible change in the patient's condition that necessitates urgent attention.
A 2-year-old child with a diagnosis of autism spectrum disorder is being discharged. What should the nurse include in the discharge teaching?
- A. Maintain a structured routine
- B. Encourage social interaction
- C. Use positive reinforcement
- D. Use a communication board
Correct Answer: A
Rationale: The correct answer is to maintain a structured routine. Children with autism spectrum disorder benefit from a structured routine as it provides them with stability and predictability, which can help reduce anxiety and improve behavior management. Encouraging social interaction (Choice B) may not be suitable for all children with autism, as some may struggle with social skills. While positive reinforcement (Choice C) is a helpful strategy, maintaining a structured routine is more essential for overall management in children with autism spectrum disorder. Using a communication board (Choice D) may be beneficial for communication, but establishing a structured routine is a foundational strategy that should be prioritized in the discharge teaching for a child with autism spectrum disorder.
What definitive diagnostic procedure does the nurse expect to be used to confirm the diagnosis of Hirschsprung disease in a 1-month-old infant?
- A. Colonoscopy
- B. Rectal biopsy
- C. Multiple saline enemas
- D. Fiberoptic nasoenteric tube
Correct Answer: B
Rationale: Rectal biopsy is the definitive diagnostic procedure for Hirschsprung disease in infants. This procedure reveals the absence of ganglion cells in the affected bowel segment, which is a hallmark of Hirschsprung disease. Colonoscopy (Choice A) is not typically used for diagnosing Hirschsprung disease due to the risk of not accurately reaching the affected segment. Multiple saline enemas (Choice C) are not used to confirm the diagnosis of Hirschsprung disease. Fiberoptic nasoenteric tube (Choice D) is not a standard diagnostic procedure for Hirschsprung disease and does not provide the necessary information to confirm the absence of ganglion cells in the affected bowel segment.
A parent tells the nurse in the emergency department, 'My 3-year-old has had a fever for several days and has been vomiting.' After instituting ordered measures to reduce the fever, what nursing action is most important?
- A. Preventing shivering
- B. Restricting oral fluids
- C. Measuring output hourly
- D. Taking vital signs hourly
Correct Answer: A
Rationale: Preventing shivering is crucial in this scenario as it can increase body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat through muscle activity, which can elevate the body temperature. Restricting oral fluids (choice B) is inappropriate as maintaining hydration is vital, especially in cases of fever and vomiting. Measuring output hourly (choice C) and taking vital signs hourly (choice D) are important nursing actions but not the most critical in this case where preventing shivering takes precedence.
A 7-year-old child with a history of seizures is being discharged from the hospital. What should the nurse include in the discharge teaching for the parents?
- A. Administer antiepileptic medication as prescribed, not just when a seizure occurs
- B. Ensure the child gets adequate sleep
- C. Restrict the child's activities to prevent seizures
- D. Teach seizure first aid to family members
Correct Answer: D
Rationale: The correct answer is to teach seizure first aid to family members. This is crucial because family members need to know how to appropriately respond during a seizure to ensure the child's safety. Choice A has been corrected to emphasize that antiepileptic medication should be administered as prescribed, not just when a seizure occurs, to effectively manage the condition. Choice B, while important for overall health, is not directly related to seizure management. Choice C is not recommended as restricting activities may not prevent seizures and may hinder the child's quality of life.