Nokea
When taking a child's blood pressure, what percentage of the upper arm should the nurse ensure the cuff bladder width covers?
- A. 20%
- B. 40%
- C. 60%
- D. 80%
Correct Answer: B
Rationale: When taking a child's blood pressure, the nurse should select a cuff with a bladder width that covers 40% of the arm circumference at the midpoint of the upper arm. This ensures accurate readings. Choosing a cuff that covers less or more than 40% can lead to incorrect blood pressure measurements. Therefore, options A, C, and D are incorrect.
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According to Maslow's hierarchy, what is the most advanced need provided by the home environment?
- A. Love
- B. Self-actualization
- C. Esteem
- D. Physiological
Correct Answer: B
Rationale: The correct answer is B, self-actualization. Self-actualization is the highest level in Maslow's hierarchy of needs, representing the realization of one's full potential. While love is an essential need, self-actualization builds upon the fulfillment of basic needs like safety and love. Esteem needs relate to feelings of accomplishment and recognition, which come before self-actualization. Physiological needs such as food, water, and shelter are the most basic needs at the bottom of the hierarchy.
A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?
- A. The child may not be pain-free.
- B. The parents or nurse may push the button for a bolus if needed.
- C. The pump allows for a continuous basal rate to deliver a constant amount of medication for pain control.
- D. Monitoring is required every 1 to 2 hours to assess patient response.
Correct Answer: C
Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.
The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.)
- A. All are correct
- B. Anorexia
- C. Hypertension
- D. Purpura
Correct Answer: A
Rationale: Hemolytic uremic syndrome (HUS) typically presents with hematuria, anorexia, hypertension, and purpura due to the hemolytic anemia, thrombocytopenia, and renal failure that characterize this condition.
The nurse is educating a new nurse on the identification of pain in children. What does the nurse teach about physiologic measurements in children's pain assessment?
- A. Not useful as the only indicator for pain
- B. Best indicator of pain in children of all ages
- C. Most valuable when children also report having pain
- D. Essential to determine whether a child is telling the truth about pain
Correct Answer: A
Rationale: Physiologic manifestations of pain may vary considerably, so they do not provide a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain, the body adapts, and these signs decrease or stabilize. Physiologic measurements are of limited value and must be viewed in the context of a pain rating scale, behavioral assessment, and parental report. When the child reports pain on an appropriate pain scale, the appropriate interventions should be used. Therefore, physiologic measurements are not considered a reliable standalone indicator for pain in children, making choice A the correct answer. Choice B is incorrect because physiologic measurements alone do not serve as the best indicator of pain. Choice C is incorrect as physiologic measurements are still limited even when children report pain. Choice D is incorrect as physiologic measurements are not primarily used to determine the truthfulness of a child's pain report.
What is the most appropriate nursing action when intermittently gavage feeding a preterm infant?
- A. Allow formula to flow by gravity
- B. Avoid allowing the infant to suck on the tube
- C. Insert the tube through the nares instead of the mouth
- D. Apply gentle pressure to the syringe to deliver the formula
Correct Answer: A
Rationale: The correct action when intermittently gavage feeding a preterm infant is to allow the formula to flow by gravity. This method helps prevent overfeeding and aspiration, which can occur if the formula is delivered too quickly under pressure. Choice B is incorrect as sucking on the tube can cause complications. Choice C is incorrect as the tube is typically inserted through the mouth. Choice D is incorrect as steady pressure can lead to rapid delivery of the formula, increasing the risk of complications.