Nokea
When developing the plan of care for a child with burns requiring fluid replacement therapy, what information would the nurse expect to include?
- A. Administration of colloid initially followed by a crystalloid
- B. Determination of fluid replacement based on the type of burn
- C. Administration of most of the volume during the first 8 hours
- D. Monitoring of hourly urine output to achieve less than 1 mL/kg/hr
Correct Answer: C
Rationale: The correct answer is C. In fluid replacement therapy for burns, it is crucial to administer most of the volume during the first 8 hours to prevent shock and maintain perfusion. This rapid administration is essential to stabilize the child's condition. Choices A and B are incorrect because the initial fluid replacement in burns typically involves administering crystalloids, not colloids, and the fluid replacement is generally calculated based on the extent of the burn injury, not the type of burn. Choice D is incorrect as monitoring hourly urine output to achieve less than 1 mL/kg/hr is not recommended in burn patients; instead, urine output should be monitored to achieve 1-2 mL/kg/hr in children to ensure adequate renal perfusion.
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A 6-year-old child comes to the school nurse reporting a sore throat, and the nurse verifies that the child has a fever and a red, inflamed throat. When a parent of the child arrives at school to take the child home, the nurse urges the parent to seek treatment. The nurse is aware that the causative agent may be beta-hemolytic streptococcus, and the illness may progress to inflamed joints and an infection in the heart. What illness is of most concern to the nurse?
- A. Tetanus
- B. Influenza
- C. Scarlet fever
- D. Rheumatic fever
Correct Answer: D
Rationale: Rheumatic fever is the most concerning illness in this case. It can develop as a complication of untreated strep throat caused by beta-hemolytic streptococcus. If not properly treated, rheumatic fever can lead to serious complications such as inflamed joints and heart infections. Tetanus is caused by a toxin produced by Clostridium tetani bacteria and is not related to the symptoms described in the scenario. Influenza is a viral respiratory illness and does not typically lead to rheumatic fever. While scarlet fever is also caused by streptococcus bacteria, in this case, the symptoms described are more indicative of rheumatic fever than scarlet fever.
You are caring for a 6-year-old child with a possible fractured left arm and have reason to believe that the child was abused. How should you manage this situation?
- A. Inform the parents of your suspicions.
- B. Call the police so the parents can be arrested.
- C. Advise the parents that the child needs to be transported.
- D. Transport the child to the hospital regardless of the parents' wishes.
Correct Answer: C
Rationale: In cases where child abuse is suspected, it is crucial to prioritize the safety and well-being of the child. Advising the parents that the child needs to be transported allows for the child to receive necessary medical care without immediate confrontation. Calling the police to have the parents arrested (Choice B) may escalate the situation and should only be done after ensuring the child's safety. Informing the parents of suspicions (Choice A) may potentially place the child at further risk if the parents are the abusers. Transporting the child to the hospital regardless of the parents' wishes (Choice D) could lead to legal and ethical complications; it is important to involve the appropriate authorities and handle the situation with sensitivity and care.
.A nurse is performing a physical examination on an infant with Down syndrome. For what anomaly should the nurse assess the child?
- A. Bulging fontanels
- B. Stiff lower extremities
- C. Abnormal heart sounds
- D. Unusual pupillary reactions
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A child with a diagnosis of gastroesophageal reflux disease (GERD) is being discharged. What dietary instructions should the nurse provide?
- A. Avoid spicy foods
- B. Avoid gluten
- C. Avoid high-fat foods
- D. Avoid dairy products
Correct Answer: B
Rationale: The correct dietary instruction for a child with GERD is to avoid gluten. Gluten is a protein found in wheat, barley, and rye, and it can exacerbate GERD symptoms in some individuals. Avoiding gluten can help reduce inflammation and irritation in the gastrointestinal tract, thereby alleviating symptoms of GERD. Choices A, C, and D are incorrect because while spicy foods, high-fat foods, and dairy products can trigger GERD symptoms in some individuals, avoiding gluten specifically is more relevant for managing GERD.
A 5-year-old child with a diagnosis of asthma is being evaluated for medication management. What is an important assessment for the nurse to perform?
- A. Assess the child's sleep patterns
- B. Assess the child's dietary intake
- C. Assess the child's academic performance
- D. Assess the child's behavior at home
Correct Answer: B
Rationale: Assessing the child's dietary intake is crucial for managing asthma symptoms as certain foods can trigger or worsen asthma attacks. Monitoring dietary intake helps ensure the child receives proper nutrition and avoids triggers. Assessing sleep patterns (Choice A) may be relevant but not as directly impactful on asthma management. Academic performance (Choice C) and behavior at home (Choice D) are important aspects of a child's overall health but are not as directly related to asthma management as dietary intake.