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When planning care for a child diagnosed with rheumatic fever, what is the primary goal of nursing care?
- A. Reduce fever.
- B. Maintain fluid and electrolytes.
- C. Prevent cardiac damage.
- D. Maintain joint mobility and function.
Correct Answer: C
Rationale: The primary goal of nursing care for a child diagnosed with rheumatic fever is to prevent cardiac damage. Rheumatic fever can lead to complications affecting the heart, making it crucial to monitor and prevent cardiac involvement to avoid long-term consequences. While addressing fever and joint pain are important aspects of care, preventing cardiac damage takes precedence in managing rheumatic fever.
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A 6-year-old child with sickle cell anemia presents to the emergency department with severe pain in the legs and abdomen. The child is crying and states that the pain is unbearable. What is the nurse's priority action?
- A. Apply warm compresses to the painful areas
- B. Administer prescribed pain medication
- C. Encourage the child to drink fluids
- D. Monitor the child's oxygen saturation
Correct Answer: B
Rationale: In a sickle cell crisis, pain management is a priority to alleviate the child's suffering. Administering the prescribed pain medication is crucial to address the severe pain experienced by the child. Warm compresses, fluid intake, and oxygen saturation monitoring are important interventions but should follow the priority of pain management in this situation.
An adolescent female who is leaning forward with her hands on her knees to breathe tells the practical nurse that she has been using triamcinolone (Azmacort) inhalation aerosol before coming to the clinic. Which action should the PN implement?
- A. Obtain vital signs and assess breath sounds for wheezing.
- B. Collect a blood sample for white blood cell count.
- C. Give the client a nebulizer breathing treatment.
- D. Administer another dose of Azmacort.
Correct Answer: A
Rationale: When a patient presents with breathing difficulties, the first action should be to assess vital signs and breath sounds to evaluate the severity of the condition. This assessment will provide crucial information to determine the appropriate course of action and treatment. Collecting a blood sample for a white blood cell count, giving a nebulizer treatment, or administering another dose of Azmacort would not be the initial priority in this situation.
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.
An adolescent female who comes to the school clinic is reluctant to confide her concerns to the practical nurse (PN). The PN tells the teen that confidentiality and privacy are maintained unless a life-threatening situation arises. Which principle supports the PN's response?
- A. The adolescent should be encouraged to seek help outside of the school clinic.
- B. Disclosures from the adolescent should be kept confidential.
- C. Honest information ensures establishing a trusting relationship.
- D. Minor adolescents should not be encouraged to disclose private concerns.
Correct Answer: C
Rationale: The correct principle supporting the practical nurse's response is that honest information ensures establishing a trusting relationship. By assuring confidentiality and privacy to the adolescent unless there is a life-threatening situation, the practical nurse fosters an environment where the teen feels safe to share their concerns openly. This approach helps build trust, encouraging effective communication and support for the adolescent's well-being.
A 4-year-old child is brought to the clinic with complaints of ear pain and fever. The practical nurse suspects otitis media. Which symptom supports this suspicion?
- A. Clear nasal discharge.
- B. Dry, hacking cough.
- C. Tugging at the ear.
- D. Sore throat.
Correct Answer: C
Rationale: Tugging at the ear is a common symptom in children with otitis media. It often indicates discomfort or pain in the ear, suggesting inflammation or infection in the middle ear. This behavior is frequently observed in young children who are unable to express their discomfort verbally, making it a significant clinical indicator for otitis media in this age group.