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Which of the following nursing diagnoses would be appropriate for the nurse to identify as a priority diagnosis for an infant just admitted to the hospital with a diagnosis of gastroenteritis?
- A. Pain related to repeated episodes of vomiting.
- B. Deficient fluid volume related to excessive losses from severe diarrhea.
- C. Impaired parenting related to infant's loss of feeding pattern.
- D. Impaired urinary elimination related to increased fluid intake.
Correct Answer: B
Rationale: Fluid loss from diarrhea is the most urgent concern in gastroenteritis.
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When teaching the family of an older infant who has had a hip spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?
- A. It can be adjusted to a position of comfort.
- B. It is used to lift the child.
- C. It adds strength to the cast.
- D. It is necessary to turn the child.
Correct Answer: C
Rationale: The abduction stabilizer bar maintains the legs in abduction to promote hip joint stability and adds structural strength to the cast.
A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the infant is not developing appropriately. Which findings in the infant would indicate the need for further developmental screening?
- A. Has no interest in peek-a-boo games.
- B. Does not turn front to back.
- C. Does not babble.
- D. Continues to have head lag.
Correct Answer: D
Rationale: Head lag at 4 months suggests delayed motor development, requiring further evaluation.
The nurse explains to the parents of a 1-year-old child admitted to the hospital in sickle cell crisis that the local tissue damage the child has on admission is caused by which of the following?
- A. Inadequate supply of vitamin K.
- B. Poorly oxygenated blood in the tissues.
- C. The formation of abnormal red blood cells.
- D. Inadequate tissue perfusion related to infarction.
Correct Answer: D
Rationale: In sickle cell crisis, sickle-shaped red blood cells obstruct blood flow, leading to inadequate tissue perfusion and infarction, causing local tissue damage.
A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The physician is calling in a telephone order for ampicillin. The nurse should do which of the following? Select all that apply.
- A. Ask the unit clerk to listen on the speaker phone with the nurse and write down the order.
- B. Ask the physician to come to the hospital and write the order.
- C. Repeat the order to the physician.
- D. Ask the physician to confirm that the order is correct as understood by the nurse.
- E. Ask the nursing supervisor to cosign the telephone order as transcribed by the nurse.
Correct Answer: C,D
Rationale: Repeating the order to the physician and asking for confirmation ensures accuracy and safety in transcribing the telephone order for ampicillin.
Which of the following statements should the nurse use to describe to the parents why their child with leukemia is at risk for infections?
- A. Play activities are too strenuous.
- B. Vitamin C intake is reduced over a period of time.
- C. The number of red blood cells is inadequate for carrying oxygen.
- D. Immature white blood cells are incapable of handling an infectious process.
Correct Answer: D
Rationale: Immature white blood cells in leukemia cannot effectively fight infections, increasing risk. Other options are unrelated.