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Which nursing action is developmentally appropriate when caring for a hospitalized school-age child?
- A. Providing brochures regarding sexuality
- B. Giving clear instructions about details of treatment
- C. Offering medical equipment to play with prior to a procedure
- D. Using toys for distraction during a painful procedure
Correct Answer: C
Rationale: Offering medical equipment to play with prior to a procedure is developmentally appropriate when caring for a hospitalized school-age child. Allowing the child to familiarize themselves with the equipment helps reduce fear and anxiety about the upcoming procedure. Choices A, B, and D are not as appropriate for a school-age child. Providing brochures regarding sexuality is not developmentally appropriate for this age group. Giving clear instructions about treatment details may overwhelm a child of this age. Using toys for distraction during a painful procedure is more suitable for younger children.
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An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?
- A. Monitor closely for signs of infection.
- B. Place the child with the operative side of the head up.
- C. Avoid pumping the shunt reservoir to maintain patency.
- D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.
Correct Answer: A
Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.
Following treatment for iron deficiency anemia, the physician orders lab tests. Which lab value would indicate an improvement in the child's condition?
- A. Low hemoglobin
- B. Normal platelet count
- C. High reticulocyte count
- D. Low hematocrit
Correct Answer: C
Rationale: A high reticulocyte count indicates that the bone marrow is producing more red blood cells, which is a sign of recovery from anemia as the body replenishes its iron stores and increases hemoglobin levels. Low hemoglobin (Choice A) would indicate ongoing anemia rather than improvement. A normal platelet count (Choice B) and low hematocrit (Choice D) are not specific indicators of improvement in iron deficiency anemia.
Picking up a pencil demonstrates the ability to use which of the following?
- A. Pincer grasp
- B. Prehension
- C. Parachute reflex
- D. Grasp reflex
Correct Answer: A
Rationale: Picking up a pencil requires the use of the pincer grasp, which involves the coordination of the thumb and forefinger to hold small objects. The pincer grasp is a fine motor skill essential for tasks that necessitate precision and dexterity. Choices B, C, and D are incorrect. Prehension refers to the act of grasping or holding an object, parachute reflex is a protective response to sudden movement or loss of support, and grasp reflex is an automatic closing of the hand when an object is placed in the palm, none of which specifically relate to the action of picking up a pencil.
What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?
- A. Isotonic dehydration
- B. Hypotonic dehydration
- C. Hypertonic dehydration
- D. Hyperosmotic dehydration
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is a primary consideration for complications when planning nursing care for an infant with Meconium aspiration syndrome?
- A. Hypoglycemia
- B. Bowel obstruction
- C. Airway obstruction
- D. Carbon dioxide retention
Correct Answer: C
Rationale: The correct answer is C: Airway obstruction. When planning nursing care for an infant with Meconium aspiration syndrome, a primary consideration for complications is the potential of airway obstruction. After the passage of meconium into the amniotic fluid, the infant may inhale or swallow the fluid, leading to meconium aspiration into the lower airways and causing a partial airway obstruction. This can result in respiratory distress and hypoxemia. Hypoglycemia (choice A) is a metabolic condition unrelated to meconium aspiration. Bowel obstruction (choice B) with meconium may indicate other conditions like cystic fibrosis or Hirschsprung disease, not directly related to meconium aspiration syndrome. Carbon dioxide retention (choice D) is not a primary consideration in meconium aspiration syndrome; instead, the focus is on addressing the airway obstruction and potential respiratory compromise.