Nokea
When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which of the following goals?
- A. Meeting the child's nutritional needs for optimal growth.
- B. Ensuring that the special diet is started at age 3 weeks.
- C. Permitting serum phenylalanine level higher than 12 mg/100 mL.
- D. Maintaining serum phenylalanine level lower than 2 mg/100 mL.
Correct Answer: A
Rationale: The goal is to meet nutritional needs via a phenylalanine-restricted diet for growth while preventing neurological damage. The diet starts at diagnosis, not 3 weeks, and phenylalanine levels should be 2-6 mg/100 mL.
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A child with newly diagnosed osteomyelitis has nausea and vomiting. The parent wishes to give the child ginger snaps to help control the nausea. The nurse should tell the parent:
- A. I will need to get an order.'
- B. Your child needs medication for the vomiting.'
- C. We discourage the use of home remedies in children.'
- D. Ginger snaps are safe and may help with nausea.'
Correct Answer: D
Rationale: Ginger snaps are a safe, non-medicinal option that may help alleviate nausea in children.
The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first:
- A. Administer oxygen.
- B. Institute rewarming.
- C. Prepare for intubation.
- D. Start an intravenous infusion.
Correct Answer: A
Rationale: Administering oxygen addresses hypoxia, the primary concern in near-drowning, to stabilize the child's condition.
The parents report that their 1-day-old is drooling and having choking episodes with excessive amounts of mucus and color changes, especially during feedings. When contacting the physician about these symptoms the nurse should request:
- A. A referral to a lactation consultant.
- B. That the physician further assess the client.
- C. An order for an x-ray with orogastric catheter placement.
- D. A serum blood glucose level per laboratory.
Correct Answer: C
Rationale: These symptoms suggest tracheoesophageal fistula, and an x-ray with orogastric catheter placement can confirm the diagnosis by visualizing the anatomy.
When developing the plan of care for an infant with a cleft lip before corrective surgery is performed, which of the following should be a priority?
- A. Maintaining skin integrity in the oral cavity.
- B. Using techniques to minimize crying.
- C. Altering the usual method of feeding.
- D. Preventing the infant from putting fingers in the mouth.
Correct Answer: C
Rationale: Altering feeding methods is critical to ensure adequate nutrition and prevent aspiration due to the anatomical defect of a cleft lip.
A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following?
- A. Protest.
- B. Despair.
- C. Regression.
- D. Detachment.
Correct Answer: A
Rationale: The toddler's fussing, crying, and pushing the nurse away when the parents attempt to leave indicate the protest phase of separation anxiety, where the child actively resists separation from caregivers.