Nokea
Which of the following actions should the nurse take first?
- A. Observe the child's throat with a flashlight.
- B. Give the child small sips of water.
- C. Administer an analgesic.
- D. Offer the child an ice collar.
Correct Answer: A
Rationale: The correct answer is A: Observe the child's throat with a flashlight. This is the first action the nurse should take as it helps assess for any signs of inflammation, infection, or obstruction in the throat, which could be causing the child's symptoms. By observing the throat, the nurse can gather important information to guide further interventions.
Choice B: Giving the child small sips of water can be important but should come after assessing the throat to ensure it is safe to swallow. Choice C: Administering an analgesic should be based on the assessment findings, not the first action. Choice D: Offering an ice collar is not indicated until the cause of the symptoms is identified.
You may also like to solve these questions
The nurse should identify which of the following findings as a potential indicator of physical abuse?
- A. Front deciduous teeth missing
- B. Weight in 45th percentile
- C. Bruising around the wrists
- D. Abrasions on the knees
Correct Answer: C
Rationale: The correct answer is C, bruising around the wrists. This is indicative of physical abuse as it suggests grabbing or restraining. Front deciduous teeth missing (A) is more likely due to normal tooth loss. Weight in 45th percentile (B) is within a healthy range. Abrasions on the knees (D) are common in children.
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
- A. The child maintains balance when standing with eyes closed.
- B. The child exhibits a gag reflex when stimulated with a tongue blade.
- C. The child correctly identifies specific scents.
- D. The child has symmetrical jaw strength when biting down.
Correct Answer: D
Rationale: The correct answer is D because symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, which controls the muscles of mastication. Choice A relates to the vestibular system, not the trigeminal nerve. Choice B involves the glossopharyngeal and vagus nerves. Choice C is related to the olfactory nerve.
Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will ensure that my child consumes a high-calorie diet.
- B. I will expect my child to need annual sweat chloride testing.
- C. I will have my child chew the pancrelipase medication before eating.
- D. I will administer dormase alfa every 4 hours for wheezing.
Correct Answer: A
Rationale: The correct answer is A because ensuring the child consumes a high-calorie diet demonstrates an understanding of the teaching regarding managing cystic fibrosis, a condition that requires a high-calorie intake to maintain weight and overall health. This statement aligns with the need for nutritional support in cystic fibrosis management.
Choice B is incorrect because annual sweat chloride testing is not related to dietary management. Choice C is incorrect as chewing pancrelipase medication before eating is not necessary for understanding the teaching about cystic fibrosis. Choice D is incorrect as administering dormase alfa every 4 hours for wheezing does not pertain to dietary requirements in cystic fibrosis.
Which of the following laboratory findings should the nurse expect?
- A. Decreased prothrombin time
- B. Increased Hgb level
- C. Increased RBC
- D. Decreased platelet count
Correct Answer: D
Rationale: The correct answer is D: Decreased platelet count. This is expected in a patient with thrombocytopenia, which is a condition characterized by low platelet levels. Thrombocytopenia can lead to abnormal bleeding and bruising due to impaired blood clotting.
A: Decreased prothrombin time would not be expected in thrombocytopenia, as it measures the clotting ability of the plasma, not platelets.
B: Increased Hgb level and C: Increased RBC levels are not typically associated with thrombocytopenia.
In summary, a decreased platelet count is the most relevant laboratory finding to expect in a patient with thrombocytopenia.
Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
- A. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.
- B. Provide a pacifier coated with an oral sucrose solution prior to the injections.
- C. Inject the immunizations into the deltoid muscle.
- D. Use a 20-gauge needle for the injections.
Correct Answer: B
Rationale: The correct answer is B: Provide a pacifier coated with an oral sucrose solution prior to the injections. This is an appropriate action for atraumatic care because it helps to reduce pain and distress during procedures, such as injections, by utilizing non-pharmacological comfort measures. The sucrose solution on the pacifier helps to soothe and distract the child, making the experience less traumatic.
Choice A (Apply EMLA cream immediately before injections) is incorrect because while EMLA cream numbs the skin, it does not address the psychological aspect of pain and distress associated with procedures.
Choice C (Inject the immunizations into the deltoid muscle) is incorrect because the location of injection does not directly relate to atraumatic care.
Choice D (Use a 20-gauge needle for the injections) is incorrect because the size of the needle does not address the psychological comfort of the child during the procedure.