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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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When teaching parents of a 5-year-old child with sickle cell anemia about pain management, what information should be included?
- A. Apply cold compresses to painful areas.
- B. Encourage the child to rest as much as possible.
- C. Administer prescribed pain medication at the first sign of pain.
- D. Offer a high-protein diet to help with pain management.
Correct Answer: C
Rationale: Administering prescribed pain medication at the first sign of pain is crucial in managing sickle cell anemia-related pain effectively. Prompt administration helps prevent the pain from escalating and becoming severe, enhancing the child's comfort and quality of life. Cold compresses, rest, and diet modifications may play supportive roles but are not as directly impactful in addressing acute pain episodes associated with sickle cell anemia.
A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?
- A. Describe the side-lying, knees to chest position that must be assumed during the procedure.
- B. Tell the child to expect loud clicking noises during the procedure that may be slightly annoying.
- C. Reassure the child that there will be no restrictions on activity after the procedure is completed.
- D. Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain?
- A. Understanding of the quality control process used to troubleshoot the pump
- B. Interpretation of fingerstick glucose levels that influence diet selections
- C. Knowledge of her glycosylated hemoglobin A1c levels for the past year
- D. Ability to perform the pump for basal insulin with mealtime boluses
Correct Answer: A
Rationale: In a patient transitioning to an insulin pump, understanding the quality control process to troubleshoot the pump is essential for ensuring proper and safe management of diabetes. This knowledge enables the individual to identify and address any issues that may arise with the pump, helping maintain optimal glycemic control and prevent complications.
A 14-year-old adolescent with a history of substance abuse is brought to the emergency department by the parents, who suspect that the adolescent has relapsed. What is the nurse's priority action?
- A. Obtain a urine sample for toxicology screening
- B. Discuss treatment options with the parents
- C. Establish a therapeutic relationship with the adolescent
- D. Administer a medication to reverse the effects of the substance
Correct Answer: A
Rationale: In this scenario, the nurse's priority action should be to obtain a urine sample for toxicology screening. This step is crucial in identifying the substances involved in the relapse, which will guide appropriate treatment strategies. Establishing a therapeutic relationship and discussing treatment options come after obtaining necessary diagnostic information to ensure a comprehensive care plan.
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.