Nokea
What comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect?
- A. He is always hungry.
- B. He tires out during feedings.
- C. He is fussy for several hours every day.
- D. He sleeps all the time.
Correct Answer: B
Rationale: Observing a 1-month-old tiring out during feedings should alert the nurse to the possibility of a congenital heart defect. This symptom may indicate that the infant is expending excess energy to compensate for a heart issue, leading to fatigue during feeding. Choices A, C, and D do not directly relate to a congenital heart defect. Being always hungry, fussy, or sleeping a lot are not specific signs of a congenital heart defect in a 1-month-old.
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What is the most important intervention to decrease the stressors of hospitalization for a 9-month-old infant being treated for a bacterial infection?
- A. Encourage the infant's parents to remain at the bedside and actively participate in the infant's care.
- B. Provide a brightly lit environment for the infant.
- C. Play tapes of the mother's voice.
- D. Assign the same nurse to the infant as much as possible.
Correct Answer: A
Rationale: Encouraging the infant's parents to remain at the bedside and actively participate in the infant's care is crucial in decreasing the stressors of hospitalization for the infant. Parental presence provides comfort and security, promotes bonding, and maintains a sense of familiarity for the infant during a potentially stressful situation. This involvement can help reduce anxiety and promote better outcomes for the infant's emotional well-being and overall hospital experience. Providing a brightly lit environment (choice B) can actually increase stress for the infant, as infants generally prefer dimly lit environments for better sleep. Playing tapes of the mother's voice (choice C) may offer some comfort but does not substitute for parental presence. While assigning the same nurse to the infant (choice D) can provide continuity of care, it is not as effective as having the parents present for emotional support and bonding.
Fred is a 12-year-old boy diagnosed with pneumococcal pneumonia. Which of the following would Nurse Nica expect to assess?
- A. Mild cough
- B. Slight fever
- C. Chest pain
- D. Bulging fontanel
Correct Answer: C
Rationale: Chest pain is a common symptom seen in patients with pneumococcal pneumonia. It can result from inflammation of the pleura or irritation of the diaphragm due to the infection. While cough and fever are also common symptoms, chest pain is particularly significant in pneumonia cases as it can be a distressing symptom for the patient and may indicate complications or severity of the infection. Bulging fontanel, on the other hand, is more indicative of conditions affecting infants and is not typically associated with pneumococcal pneumonia in a 12-year-old boy.
A 2-year-old client is admitted for an acute asthma episode. The hospital provides family-centered care. In explaining the program to the parents, the nurse would explain that the parents are:
- A. Required to implement all personal hygiene care for their child.
- B. Encouraged to be as involved with the child's care as they are comfortable being.
- C. Requested to administer all oral medications.
- D. Expected to be present at the child's bedside.
Correct Answer: B
Rationale: Family-centered care involves encouraging parents to actively participate in their child's care based on their comfort level. This approach promotes collaboration between healthcare providers and families, enhancing the quality of care and ensuring the family's involvement in decision-making. Choice A is incorrect because parents are encouraged to participate, not required to implement all personal hygiene care. Choice C is incorrect as it implies a specific action rather than the broader concept of involvement. Choice D is incorrect as it focuses solely on physical presence rather than active participation in care.
Beta-adrenergic agonists such as Salbutamol are given to Reggie, a child with asthma. Such drugs are administered primarily to do which of the following?
- A. Dilate the bronchioles
- B. Reduce secondary infections
- C. Decrease postnasal drip
- D. Reduce airway inflammation
Correct Answer: A
Rationale: Beta-adrenergic agonists like Salbutamol are used to dilate the bronchioles in asthma patients. This action helps in relieving bronchospasms and improving airflow to the lungs, making breathing easier for the individual. While reducing inflammation is an essential part of asthma management, beta-adrenergic agonists primarily work by relaxing the smooth muscles around the airways, leading to bronchodilation. Choices B, C, and D are incorrect because beta-adrenergic agonists are not primarily used to reduce secondary infections, decrease postnasal drip, or directly reduce airway inflammation in asthma patients.
Which behavior is most indicative that a 2-year-old is experiencing the initial phase of separation anxiety because his parents cannot stay all day at the hospital with him?
- A. He withdraws from the nursing staff.
- B. He cries when his parents leave.
- C. He lies quietly in bed.
- D. He cries when his parents arrive.
Correct Answer: B
Rationale: The most indicative behavior of a 2-year-old experiencing the initial phase of separation anxiety due to parents not staying all day at the hospital is crying when his parents leave. This behavior is a common manifestation of separation anxiety in children, as they struggle with the absence of their primary attachment figures. Choices A, C, and D are less indicative because withdrawing from the nursing staff, lying quietly in bed, or crying when parents arrive do not specifically demonstrate the distress caused by separation from parents, which is the hallmark of separation anxiety in children.