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When caring for a child with an intravenous (IV) infusion, what is an appropriate nursing action?
- A. Change the insertion site every 24 hours.
- B. Check the insertion site frequently for signs of infiltration.
- C. Use a macrodropper to facilitate reaching the prescribed flow rate.
- D. Avoid restraining the child to prevent undue emotional stress.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?
- A. Monitor closely for signs of infection.
- B. Place the child with the operative side of the head up.
- C. Avoid pumping the shunt reservoir to maintain patency.
- D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.
Correct Answer: A
Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.
What is a suitable nutritional goal for a preschool-aged child?
- A. Minimize messiness and spills.
- B. Introduce new foods gradually and provide variety.
- C. Finish all the food on the plate.
- D. Allow the child to eat only preferred foods.
Correct Answer: B
Rationale: Introducing new foods gradually and offering a variety of options is a suitable nutritional goal for preschool-aged children as it helps in providing essential nutrients and expanding their palate. Choice A is incorrect as reducing messiness and spills is more related to behavior than nutrition. Choice C is incorrect as forcing a child to finish all the food on the plate may override their natural hunger and fullness cues. Choice D is incorrect as allowing a child to eat only preferred foods may lead to an imbalanced diet lacking in essential nutrients.
The nurse is preparing to administer an intramuscular injection to a toddler-age client. Which is the most appropriate statement by the nurse prior to this procedure?
- A. "We will give you your shot when your mommy comes back."
- B. "I will wipe your skin with a magic wipe and then hold the needle like this and say one, two, three, go and give you your shot. Are you ready?"
- C. "It is all right to cry. After we are done, you can go to the box and pick out your favorite sticker."
- D. "This is a magic sword that will give you your medicine and make you all better."
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the child's feelings, provides clear instructions, and offers comfort and rewards to help the child cope with the procedure. Choice A is not appropriate as it may create anxiety about the injection. Choice B uses the term 'magic,' which may confuse the child and lead to fear. Choice D introduces a fantasy element that may not be beneficial in preparing the child for the injection.
When describing play by the school-aged child to a group of nursing students, the instructor would emphasize the need for which of the following?
- A. Recreation
- B. Ritualism
- C. Physical activity
- D. Rules
Correct Answer: D
Rationale: The correct answer is D: Rules. When discussing play in school-aged children, rules are essential as they help in structuring games and social interactions. Rules provide a framework for play, ensuring fairness and cooperation among children. Choice A, recreation, is too broad and doesn't specifically address the importance of rules in play. Choice B, ritualism, is unrelated to the concept of play in school-aged children. Choice C, physical activity, is important for overall health but doesn't capture the specific aspect of rules that are crucial in the play of school-aged children.
Which immunization should the nurse include in a teaching session for parents of toddler-age clients to decrease the risk for epiglottitis?
- A. Hepatitis B
- B. Polio
- C. Measles, mumps, and rubella (MMR)
- D. Hemophilus influenzae type B (Hib)
Correct Answer: D
Rationale: The correct answer is D, Hemophilus influenzae type B (Hib) vaccine. Hib vaccine is crucial in preventing epiglottitis, a serious respiratory condition caused by Haemophilus influenzae type b bacteria. This vaccine is recommended for toddlers to protect them from developing epiglottitis. Choices A, B, and C are incorrect because while they are important vaccines for children, they do not specifically target the prevention of epiglottitis, unlike the Hib vaccine.