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Which of the following should the nurse include when completing discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) and being discharged to home?
- A. Offer the child extra fluids every 2 hours for 2 weeks.
- B. Take the child's temperature daily for several days.
- C. Check the child's blood pressure daily until the follow-up appointment.
- D. Call the physician if the irritability lasts for 2 more weeks.
Correct Answer: B
Rationale: Monitoring temperature daily helps detect persistent fever, a sign of ongoing inflammation in Kawasaki disease. Other options are less critical or impractical at home.
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The nurse formulates the nursing diagnosis Imbalanced Nutrition: Less than body requirements related to negative feeding patterns for a 5-month-old infant diagnosed with failure to thrive. To meet the short-term outcomes of the infant's plan of care, the nurse should expect to do which of the following?
- A. Instruct the parents in proper feeding techniques.
- B. Give infant formula that has 24 calories/ounce.
- C. Provide consistent staff to care for the infant.
- D. Allow the infant to sit in a high chair during feedings.
Correct Answer: A
Rationale: Teaching proper feeding techniques corrects negative patterns, improving intake. Higher-calorie formula or consistent staff are secondary, and high chairs are unsuitable for a 5-month-old.
The parent of a 17-year-old boy, who is hospitalized for complications related to type I diabetes, requests to review the adolescent's medical record. The client reported receiving mental health counseling during the admission history, but did not want his parent to know. The nurse, who is uncertain of how to protect the adolescent's privacy and accommodate the parent's request, should consult:
- A. The unit nurse manager.
- B. The primary care provider.
- C. The organization's privacy officer.
- D. The customer service representative.
Correct Answer: C
Rationale: The privacy officer is trained to handle HIPAA and confidentiality issues, ensuring the adolescent's privacy (e.g., mental health records) is protected while addressing parental rights.
A child is admitted with a fracture of the femur and placed in skeletal traction. What should the nurse assess first?
- A. The pull of traction on the pin.
- B. The Ace bandage.
- C. The pin sites for signs of infection.
- D. The dressings for tightness.
Correct Answer: C
Rationale: Assessing pin sites for infection is the priority, as infection can lead to serious complications in skeletal traction.
A school-age client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with acute poststreptococcal glomerulonephritis. Which of the following actions should receive the highest priority?
- A. Assessing vital signs every 4 hours.
- B. Monitoring intake and output every 12 hours.
- C. Obtaining daily weight measurements.
- D. Obtaining serum electrolyte levels daily.
Correct Answer: C
Rationale: Weight reflects fluid status.
Nonsteroidal anti-inflammatory drugs are the first choice in treating a child with juvenile idiopathic arthritis. Which adverse effects should the nurse include in the teaching plan for the parents? Select all that apply.
- A. Weight gain.
- B. Abdominal pain.
- C. Blood in the stool.
- D. Folic acid deficiency.
- E. Reduced blood clotting ability.
Correct Answer: B,C,E
Rationale: NSAIDs can cause gastrointestinal issues like abdominal pain and blood in the stool, and they may reduce blood clotting ability due to their effect on platelet function.