Nokea
Which intervention is not appropriate for the hospitalized adolescent?
- A. Allowing the adolescent to assist with procedures when possible.
- B. Encouraging them to discuss their thoughts and feelings about the hospitalization.
- C. Encouraging them to remain in the room throughout the hospitalization to ensure adequate rest periods.
- D. Encouraging peer visitation.
Correct Answer: C
Rationale: Encouraging the adolescent to remain in the room throughout the hospitalization to ensure adequate rest periods is not appropriate. It is crucial for adolescents to have opportunities for physical activity and social interaction to promote their well-being during hospitalization. Allowing them to assist with procedures when possible can empower them and provide a sense of control. Encouraging discussions about their thoughts and feelings helps address their emotional needs. Facilitating peer visitation fosters social support, which is beneficial for their well-being. Therefore, choice C is the least appropriate as it restricts important aspects of the adolescent's development and coping mechanisms during hospitalization.
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A clinic nurse reviews the record of a child just seen by a doctor and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?
- A. Pallor
- B. Hyperactivity
- C. Exercise intolerance
- D. Gastrointestinal disturbances
Correct Answer: C
Rationale: Aortic stenosis is a condition characterized by the narrowing of the aortic valve, leading to reduced blood flow from the heart to the body. This narrowing restricts the amount of oxygenated blood that can reach various tissues, including muscles. As a result, individuals with aortic stenosis may experience exercise intolerance, as their muscles may not receive an adequate oxygen supply during physical activity. This can manifest as fatigue, shortness of breath, and overall decreased exercise capacity. Pallor (choice A) is a pale appearance that may be seen in anemia or other conditions affecting blood flow but is not specific to aortic stenosis. Hyperactivity (choice B) and gastrointestinal disturbances (choice D) are not typically associated with aortic stenosis.
Which type of diabetes mellitus (DM) is most likely the result of heterogeneous risk factors, making it preventable?
- A. Type 1
- B. Type 2
- C. Type 1 and 2
- D. Gestational diabetes
Correct Answer: B
Rationale: Type 2 diabetes mellitus is most likely the result of heterogeneous risk factors, such as lifestyle choices and genetics, making it preventable. Type 1 diabetes, on the other hand, is an autoimmune condition that is not preventable. Gestational diabetes occurs during pregnancy and is not entirely preventable. Type 1 and 2 diabetes are distinct conditions, with Type 2 being the type associated with preventable risk factors.
How would you classify a child at two years of age who has fast breathing without chest indrawing or stridor when calm?
- A. Very severe disease
- B. Pneumonia
- C. No pneumonia
- D. Local infection
Correct Answer: B
Rationale: In pediatric clinical assessment, a child at two years of age with fast breathing but without chest indrawing or stridor when calm is classified as having pneumonia. Fast breathing in this context is a key symptom used in the Integrated Management of Childhood Illness (IMCI) guidelines to diagnose pneumonia in children under five years old. The absence of chest indrawing or stridor when the child is calm helps differentiate this case from other respiratory conditions, making pneumonia the likely classification. Choices A, C, and D are incorrect. 'Very severe disease' is too broad and not specific to the symptoms described. 'No pneumonia' is also incorrect as the symptoms match the presentation of pneumonia. 'Local infection' is too vague and does not specifically address the respiratory symptoms observed.
Based on the complaints provided by Madam KK, is the child exhibiting danger signs?
- A. Yes
- B. No
- C. I don't know
- D. Yes
Correct Answer: A
Rationale: Yes, the child is displaying danger signs with symptoms such as fever and rapid breathing, indicating a potential serious health issue that requires immediate attention. The correct answer is 'Yes' because the symptoms described in Madam KK's complaints align with danger signs that suggest a severe health problem. Choices B and C are incorrect because the symptoms mentioned clearly indicate the presence of danger signs. Choice D is a duplicate of choice A and does not provide a valid alternative.
A 3-year-old is seen in the clinic and is diagnosed with an ear infection. The father reports that the child was awake several times during the night, crying. The PRIORITY nursing diagnosis for this child is:
- A. Sleep Pattern Disturbance related to pain.
- B. Pain related to ear infection.
- C. Altered Family Processes related to ill child.
- D. Ineffective Thermoregulation Related to Infection
Correct Answer: B
Rationale: The priority nursing diagnosis for a child diagnosed with an ear infection and experiencing nighttime awakenings and crying would be 'Pain related to ear infection.' Pain management is crucial to ensure the child's comfort and well-being, which can also impact their sleep patterns. Addressing the pain as a priority can lead to improved sleep and overall recovery for the child.