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Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
- A. Hemorrhagic skin rash.
- B. Edema.
- C. Cyanosis.
- D. Dyspnea on exertion.
Correct Answer: A
Rationale: A hemorrhagic rash, such as petechiae or purpura, is a hallmark of disseminated intravascular coagulation in meningitis, indicating clotting abnormalities.
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Which of the following outcome criteria would the nurse develop for a child with cystic fibrosis who has a nursing diagnosis of Ineffective airway clearance related to increased pulmonary secretions and inability to expectorate?
- A. Respiratory rate and rhythm within expected range.
- B. Absence of chills and fever.
- C. Ability to engage in age-related activities.
- D. Ability to tolerate usual diet without vomiting.
Correct Answer: A
Rationale: A respiratory rate and rhythm within the expected range is an appropriate outcome for ineffective airway clearance, indicating improved mucus clearance and respiratory function.
An infant is admitted to the pediatric unit with a diagnosis of hypertrophic pyloric stenosis after vomiting for several days. Which of the following nursing diagnoses should be the priority?
- A. Deficient fluid volume related to prolonged vomiting.
- B. Ineffective airway clearance related to impaired swallowing.
- C. Imbalanced nutrition: Less than body requirements.
- D. Bowel incontinence related to abdominal pain.
Correct Answer: A
Rationale: Prolonged vomiting in pyloric stenosis leads to significant fluid loss, making fluid volume deficit the priority.
The nurse discusses with the parents how best to raise the IQ of their child with Down syndrome. Which of the following would be most appropriate?
- A. Serving hearty, nutritious meals.
- B. Giving vasodilator medications as prescribed.
- C. Letting the child play with more able children.
- D. Providing stimulating, nonthreatening life experiences.
Correct Answer: D
Rationale: Stimulating, nonthreatening experiences promote cognitive development by encouraging exploration and learning within the child's capabilities.
A 17-year-old female with severe nodular acne is considering treatment with isotretinoin (Accutane). Prior to beginning the medication, the nurse explains that the client will be required to:
- A. Enroll in a risk management plan.
- B. Egypt in a risk management plan.
- C. Begin an effective form of birth control.
- D. Temporarily give up sports.
Correct Answer: C
Rationale: Isotretinoin has a high risk of teratogenicity, requiring strict contraception to prevent pregnancy during treatment. A risk management plan (e.g., iPLEDGE) is also required, but the most critical initial step emphasized is effective birth control.
A child has just ingested about 10 adult-strength acetaminophen (Tylenol) pills. The mother brings the child to the emergency department. What should the nurse do? Place the interventions in the order of priority from first to last.
- A. Administer activated charcoal.
- B. Assess the airway.
- C. Reassure the mother.
- D. Check serum acetaminophen levels.
- E. Obtain information about how the child obtained the pills.
- F. Complete a physical examination.
Correct Answer: B,A,D,C,F,E
Rationale: 1. Assess the airway to ensure patency and stability. 2. Administer activated charcoal to reduce acetaminophen absorption. 3. Check serum acetaminophen levels to guide treatment. 4. Reassure the mother to reduce anxiety. 5. Obtain information about how the child obtained the pills for safety education. 6. Complete a physical examination to assess for other effects.