Nokea
While auscultating the lung sounds of a 5-year-old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. What action is best for the nurse to take?
- A. Identify the antibiotics used for treating the pneumonia.
- B. Inquire about the use of alternative treatment methods.
- C. Ask the parents if the child has been in a recent accident.
- D. Report suspected child abuse to the authorities.
Correct Answer: B
Rationale: Inquiring about the use of alternative treatment methods is essential to understand cultural practices and provide holistic care. It allows the nurse to gather more information about the blemishes and potentially uncover traditional or alternative healing approaches that the family may have used. This approach demonstrates cultural sensitivity and a comprehensive assessment before making assumptions or taking further actions. Identifying the antibiotics used for treating pneumonia (Choice A) is not immediately necessary in this context as the focus is on the blemishes. Asking about a recent accident (Choice C) assumes a traumatic cause without evidence. Reporting suspected child abuse (Choice D) is premature without further assessment or evidence of abuse.
You may also like to solve these questions
A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider?
- A. Gastric output of 100 mL in the last 8 hours.
- B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
- C. Serum potassium of 3.0 mEq/L.
- D. Serum pH of 7.45.
Correct Answer: C
Rationale: A serum potassium level of 3.0 mEq/L is significantly low and indicates hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Therefore, it is crucial for the nurse to report this finding promptly to the healthcare provider for immediate intervention. The other findings are not as critical in this situation. Gastric output of 100 mL in the last 8 hours may be expected in a patient with persistent vomiting. The shift intake of IV fluids and ice chips indicates fluid replacement, which is important but not as urgent as correcting electrolyte imbalances. A serum pH of 7.45 is within the normal range and does not indicate an immediate concern.
The nurse is assessing a 3-month-old infant who was brought to the clinic by the parents due to concerns about the infant's feeding. The parents report that the infant has been vomiting after every feeding and has not gained any weight. What should the nurse assess first?
- A. Evaluate the infant's feeding technique
- B. Check the infant's hydration status
- C. Measure the infant's abdominal circumference
- D. Review the infant's growth chart
Correct Answer: B
Rationale: Assessing hydration status is crucial in an infant who is vomiting frequently, as dehydration can quickly become a serious issue. In this scenario, the infant's inability to retain feeds and lack of weight gain may indicate a potential risk of dehydration, making it essential to prioritize checking the infant's hydration status to prevent complications. Evaluating the feeding technique (Choice A) could be important but is secondary to addressing potential dehydration. Measuring the abdominal circumference (Choice C) and reviewing the growth chart (Choice D) are not the priority in this situation where dehydration is a primary concern.
The nurse is planning for a 5-month-old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother?
- A. Give small amounts of baby food with each feeding.
- B. Thicken formula with cereal for each feeding.
- C. Dilute the child's formula with equal parts of water.
- D. Offer 10% dextrose in water between most feedings.
Correct Answer: B
Rationale: Thickening formula with cereal is a recommended intervention for infants with gastroesophageal reflux disease (GERD) to help reduce vomiting and increase caloric intake. This modification can help the infant keep the food down better, reducing reflux symptoms while providing adequate nutrition. Giving small amounts of baby food with each feeding (Choice A) is not recommended for a 5-month-old with GERD as it may exacerbate symptoms. Diluting the child's formula with equal parts of water (Choice C) can lead to inadequate nutrition and is not advisable. Offering 10% dextrose in water between most feedings (Choice D) is not appropriate for managing GERD in infants and does not address the underlying issue of reflux.
A 3-year-old child with a high fever and sore throat is brought to the clinic. The nurse observes that the child is drooling and has difficulty swallowing. What is the nurse's priority action?
- A. Administer antipyretic medication
- B. Prepare for emergency airway management
- C. Offer the child ice chips to suck on
- D. Assess the child's hydration status
Correct Answer: B
Rationale: In a 3-year-old child with drooling, difficulty swallowing, high fever, and sore throat, the nurse should prioritize preparing for emergency airway management. These signs may indicate epiglottitis, a condition that can quickly obstruct the airway, leading to respiratory distress and potentially fatal outcomes if not managed promptly. Administering antipyretic medication (Choice A) may be necessary later but is not the priority. Offering ice chips (Choice C) is contraindicated as the child has difficulty swallowing. Assessing hydration status (Choice D) is important but not the priority when the airway is at risk.
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
- A. Permanent lifestyle changes need to be made to promote safety in the home
- B. The chorea or movements are temporary and will eventually disappear
- C. Muscle tension is decreased with fine motor project skills, so these activities should be encouraged
- D. Consistent discipline is needed to help the child control the movements
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.