Nokea
While assessing the vital signs of a 10-year-old who underwent a tonsillectomy this morning, the nurse observes the child swallowing every 2-3 minutes. Which assessment should the nurse implement?
- A. Inspect the posterior oropharynx
- B. Assess for teeth clenching or grinding
- C. Touch the tonsillar pillars to stimulate the gag reflex
- D. Ask the child to speak to evaluate a change in voice tone
Correct Answer: A
Rationale: Frequent swallowing post-tonsillectomy may indicate bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or clots, which may necessitate immediate intervention. Option B is incorrect as teeth clenching or grinding is not directly related to the observation of frequent swallowing in this scenario. Option C is incorrect because stimulating the gag reflex is not necessary at this point and may be uncomfortable for the child. Option D is incorrect as evaluating a change in voice tone is not relevant to the situation of observing frequent swallowing.
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Which assessment finding should the healthcare provider identify as most concerning in a child with acute glomerulonephritis?
- A. Hypertension.
- B. Gross hematuria.
- C. Proteinuria.
- D. Periorbital edema.
Correct Answer: A
Rationale: In a child with acute glomerulonephritis, hypertension is the most concerning assessment finding as it can indicate worsening renal function. Hypertension is a common complication of glomerulonephritis and can lead to further kidney damage if not managed promptly. Monitoring and controlling blood pressure is crucial in these cases to prevent complications and preserve renal function. Gross hematuria, proteinuria, and periorbital edema are also common findings in acute glomerulonephritis but hypertension poses a higher risk for renal damage if left uncontrolled.
What response should the practical nurse (PN) provide when a school-age child asks to talk with a dying sister?
- A. Talk loudly to ensure the dying person hears and recognizes others' voices.
- B. Touch can provide a tactile presence if the dying person does not respond to words.
- C. Sitting close offers the dying person the sensation of others' presence.
- D. Although the dying person may not respond, they can still hear what is said.
Correct Answer: D
Rationale: The correct response is D because it is believed that hearing is the last sense to go. Even if the dying person does not respond, speaking to them can still provide comfort. Choice A is incorrect because talking loudly is not necessary and can be distressing. Choice B is incorrect as it focuses on touch rather than the sense of hearing. Choice C is incorrect because sitting close may not necessarily help the dying person hear better.
A child with cystic fibrosis is being discharged home with pancreatic enzyme replacement therapy. What information should the practical nurse reinforce with the parents?
- A. Give the enzymes after meals.
- B. Mix the enzymes with hot food or drinks.
- C. Enzymes should be taken before or with meals.
- D. Avoid giving enzymes with any food or drink.
Correct Answer: C
Rationale: The correct answer is C: 'Enzymes should be taken before or with meals.' Pancreatic enzymes should be taken before or with meals to assist with digestion in children with cystic fibrosis. This timing helps maximize the effectiveness of the enzymes in breaking down nutrients from food. Giving the enzymes after meals (choice A) may not provide the necessary support for digestion. Mixing the enzymes with hot food or drinks (choice B) is not recommended as it may affect the enzymes' efficacy. Avoiding giving enzymes with any food or drink (choice D) is incorrect as enzymes need to be taken in conjunction with meals to aid in digestion.
When caring for a child with Kawasaki disease, which symptom is the most significant for making this diagnosis?
- A. Desquamation of the palms and soles.
- B. Cervical lymphadenopathy.
- C. Erythema of the hands and feet.
- D. Strawberry tongue.
Correct Answer: C
Rationale: Erythema of the hands and feet is a key diagnostic criterion for Kawasaki disease. This, along with other symptoms like fever and strawberry tongue, helps in making the diagnosis. While desquamation of the palms and soles, cervical lymphadenopathy, and strawberry tongue are associated with Kawasaki disease, the presence of erythema of the hands and feet is particularly significant in diagnosing this condition.
A 15-year-old adolescent with anorexia nervosa is admitted to the hospital for severe weight loss. The nurse notes that the client has dry skin, brittle hair, and is severely underweight. What is the nurse's priority intervention?
- A. Establish a therapeutic relationship with the client
- B. Monitor the client's vital signs frequently
- C. Initiate a structured eating plan
- D. Provide education about healthy eating habits
Correct Answer: C
Rationale: In this scenario, the priority intervention for the nurse is to initiate a structured eating plan. Anorexia nervosa is a serious eating disorder characterized by severe food restriction, which can lead to malnutrition and severe weight loss. By starting a structured eating plan, the nurse can ensure the client receives the necessary nutrition to begin the process of weight restoration and recovery. Monitoring vital signs is essential, but without addressing the nutrition deficiency, vital signs may not improve significantly. Establishing a therapeutic relationship is crucial for long-term care but may not address the immediate risk of malnutrition. Providing education about healthy eating habits is important but may not be effective initially due to the severity of the client's condition.