Nokea
What is the nurse's best response when a 2-year-old boy begins to cry as the mother starts to leave?
- A. Let me read this book to you.
- B. Two-year-olds usually stop crying the minute the parent leaves.
- C. Now be a big boy. Mommy will be back soon.
- D. Let's wave bye-bye to mommy.
Correct Answer: D
Rationale: The best response for the nurse in this situation is to help the child understand that the separation is temporary. Waving bye-bye to mommy can be reassuring to the child and make the separation process easier. It acknowledges the child's feelings while providing a positive and comforting interaction.
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A child with a fever of 39°C (102.2°F) and a sore throat is brought to the clinic. The practical nurse suspects the child has streptococcal pharyngitis. Which diagnostic test should the practical nurse prepare the child for?
- A. Rapid antigen detection test.
- B. Throat culture.
- C. Complete blood count (CBC).
- D. Chest X-ray.
Correct Answer: A
Rationale: A rapid antigen detection test is the appropriate diagnostic test for suspected streptococcal pharyngitis. This test is commonly used due to its quick results, helping in the prompt diagnosis and appropriate treatment of the condition. It specifically detects the presence of streptococcal antigens in the throat, aiding in confirming the diagnosis and guiding the healthcare provider in determining the most suitable treatment plan.
What should the nurse do first for a 6-year-old with asthma showing a prolonged expiratory phase, wheezing, and 35% of personal best peak expiratory flow rate (PEFR)?
- A. Administer a prescribed bronchodilator.
- B. Encourage the child to cough and take deep breaths.
- C. Report the findings to the healthcare provider.
- D. Identify the triggers that precipitated this attack.
Correct Answer: A
Rationale: Administering a bronchodilator is the priority action in managing an acute asthma exacerbation in a child. Bronchodilators help to relax the muscles around the airways, opening them up and improving breathing. This intervention aims to address the immediate breathing difficulty and should be done promptly to provide relief for the child.
The caregiver discovers a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, what action should the caregiver take?
- A. Palpate femoral pulse and check for regularity.
- B. Deliver cycles of 30 chest compressions and 2 breaths.
- C. Give two breaths that make the chest rise.
- D. Feel the carotid pulse and check for adequate breathing.
Correct Answer: C
Rationale: Providing two breaths that make the chest rise is the correct action in this situation. This helps to deliver oxygen to the infant's lungs and body, which is crucial in a situation where the infant is not breathing. Chest rise indicates successful ventilation, and it is an essential step in pediatric resuscitation, especially for infants.
A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?
- A. Bilateral bronchial breath sounds.
- B. Diaphragmatic respiration.
- C. A resting respiratory rate of 35 breaths per minute.
- D. Flaring of the nares.
Correct Answer: D
Rationale: Flaring of the nares is a classic sign of acute respiratory distress in infants. It indicates increased work of breathing and is a visible cue that the child is struggling to breathe. This finding should alert healthcare providers to the severity of the respiratory distress and the need for prompt intervention to support the child's breathing.
A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid-base imbalance?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.