Evolve Rationals NOC

What should nursing care for a child admitted with acute glomerulonephritis be directed toward? a. enforcing bed rest b. promoting diuresis c. encouraging fluids d. removing dietary salt

b. promoting diuresis rationale: with the reduction of edema the child's health improves, the appetite increases, and the blood pressure normalizes. ambulation does not have an adverse effect on this disorder; most children voluntarily restrict their activities and remain in bed during the acute phase. fluids are not encouraged because the kidneys are inflamed and cannot tolerate large amounts of fluid. sodium intake is decreased, not eliminated; sodium restriction is not tolerated well by chidden and may further decrease their appetite.

a nurse is assessing a toddler and the dynamics of the child's family, in which abuse is suspected. what behaviors are expected? select all that apply. 1. the child cringes when approached 2. the parents cannot explain previously healed injuries 3. the parents are overly affectionate toward the child 4. the child lies still while surveying the environment 5. the parents give detailed accounts of the child's injuries.

1, 2, 4 rationale: the child cringes when approached because past experiences with adults have resulted in pain rather than comfort. evidence of past injuries may exist, but the parents do not discuss it, because this would be an admission of child abuse. abused children are always on the alert for potential abuse. lying motionless is an attempt to avoid attention; also, in the past the abused child's attempts to resist abuse have often precipitated more abuse. abusive parents are unable to provide any emotional support and will not exhibit overly affectionate behavior. because abusive parents try to hide the fact of abuse, explanations about injuries are usually fabricated, inconsistent, and vague.

A nurse is caring for a 6-year-old child who has undergone laparoscopic appendectomy. What interventions should the nurse document on the child's clinical record? Select all that apply. 1. intake and output 2. measurement of pain 3. tolerance of low-residue diet 4. frequency of dressing changes 5. presence or absence of bowel sounds

1, 2, 5 rationale: assessment and documentation of fluid balance are critical aspects of all postoperative care. laparoscopic surgery involves insufflating the abdominal cavity with air, which is painful until it has been absorbed. the degree of pain should be assessed and documented. pain can be measured with the use of numbers 1-10 for the older child and with the use of the Wong FACES scale for the younger child. auscultating for bower's sounds and documenting their presence or absence help the nurse evaluate the child's adaptation to the intestinal trauma caused by the surgery. a special diet is not indicated after this surgery. after a laparoscopic appendectomy there is little drainage and no dressings.

Which symptoms present in a child indicate Turner syndrome? Select all that apply. 1. Webbed neck 2. Impaired language 3. Tall stature with long legs 4. Low position of posterior hairline 5. Shield-shaped chest with wide space between nipples

1, 4, 5 Rationale: Turner syndrome is a chromosomal abnormality seen in females in which an X chromosome is partly or completely absent. The clinical manifestations of Turner syndrome include a webbed neck, low posterior hairline, and shield-shaped chest with wide space between the nipples. Impaired language skills are seen in clients with triple X or superfemale syndrome. The client with Turner syndrome has short stature. Tall stature with long legs is a finding in Klinefelter syndrome.

A 2-year-old boy born with cryptorchidism is to undergo orchiopexy. What should the nurse tell the parents about the anticipated outcome of this surgery? a. the urine stream will be directed downward b. damage to the undescended testicle will be prevented c. fluid that has collected in the scrotum will be removed d. the fibrous tissue that has caused the penile deformity will be released

b. damage to the undescended testicle will be prevented rationale: cryptorchidism is the failure of one or more testes to descend into the scrotal sac; orchiopexy surgically pulls the testicle downward into the scrotum. downward direction of the urine is the goal if the child has hypospadias. removal of scrotal fluid is the goal if the child has hydrocele. release of fibrous tissue is the goal if the child has chordee.

A 15-year-old with cystic fibrosis (CF) is admitted with a respiratory infection. The nurse determines that the adolescent is cyanotic, has a barrel-shaped chest, and is in the 10th percentile for both height and weight. What is the priority nursing intervention? a. increasing physical activities b. performing postural damage c. maintaining dietary restrictions d. administering prescribed pancreatic enzymes

b. performing postural drainage rationale: postural drainage, including percussion and vibration, aids removal of respiratory secretions that provide a medium for further bacterial growth. children with CF must cope with impaired has exchange that results in intolerance to activity. increasing activity at this time may be too taxing. there must be a balance between activity and rest within the child's limitations. there are no dietary restrictions. children with CF should have a balanced nutritional intake that is high in calories. although important, administration of prescribed enzymes is not the priority.

A 5-year-old child is returned to the pediatric intensive care unit after cardiac surgery. The child has a left chest tube attached to water-seal drainage, an intravenous line running of D5 ½ NS at 4 mL/hr, and a double-lumen nasogastric tube connected to continuous suction. A cardiac monitor is in place, as is a dressing on the left side of the chest dressing. What is the priority nursing intervention? a. auscultating breath sounds b. testing the LOC c. measuring the drainage from both tubes d. determining the suction pressure of the NG tube

b. testing the LOC rationale: assessing the LOC provides the nurse with information about how awake the client is and therefore how able to clear the throat and protect the airway. the airway takes priority over listening to the lung sounds (checking for breathing: ABCs--airway, breathing, circulation), measuring the drainage from both tubes, or determining the suction pressure of the NG tube.

A prescription for an isotonic enema is written for a 2-year-old child. What is the maximal amount of fluid the nurse should administer without a specific prescription from the healthcare provider? a. 100-150 mL b. 155-250 mL c. 255-360 mL d. 365-500 mL

c. 255-360 mL rationale: unless prescribed, no more than 360 mL of solution should be administered to a young child because fluid and electrolyte imbalance in infants and children is easily disturbed. between 100-150 mL may be prescribed for a small infant. between 155-250 mL may be prescribed for an older or larger infant. between 365-500 mL is too much for a toddler.

A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect? a. proteinuria b. peripheral edema c. increased hematocrit d. absence of pedal pulses

c. increased hematocrit rationale: polycythemia, reflected in an increased hematocrit reading, is a direct attempt by the body to compensate for the decrease in oxygen to all body cells caused by the mixture of oxygenated and deoxygenated circulation blood. proteinuria is not a characteristic of heart malformations that cause right-to-left shunting of blood; nor is edema. an absence of pedal pulses is characteristic of cortication of the aorta, an obstructive malformation

a nurse teaches the mother of a toddler which foods are the best sources of thiamine, a B-complex vitamin. what food that is high in thiamine should the nurse include in the teaching plan? a. eggs b. fruits c. whole grains d. green leafy vegetables

c. whole grains rationale: whole grains, legumes, and meat are excellent sources of thiamine, an essential coenzyme gator in carbohydrate metabolism. eggs and vegetables are a fair source of thiamine. fruits do not contain thiamine.

The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond? a. "A newborn's spleen can't produce efficient antibodies." b. "Infants younger than 2 months are rarely exposed to infectious disease." c. "The immunization will attack the infant's immature immune system and cause the disease." d. "Maternal antibodies interfere with the development of active antibodies by the infant when immunized."

d. "Maternal antibodies interfere with the development of active antibodies by the infant when immunized." rationale: passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases the spleen does not produce antibodies. infants often are exposed to infectious diseases. the viruses in immunizations are inactivated or attenuated; they may cause irritability and fever but will not cause the related disease.

what clinical signs should lead a nurse to suspect that a 1 yr old child has rubella (German measles)? a. bulging fontanel and nuchal rigidity b. conjunctivitis and sensitivity to light c. kopek spots on the soft palate and buccal mucosa d. enlarged posterior cervical and post auricular nodes

d. enlarged posterior cervical and post auricular nodes rationale: lymphadenopathy and the development of a rash after a day of fever, sneezing, and coughing are characteristics of rubella. a bulging fontanel and nuchal rigidity are associated with meningitis and encephalitis, not rubella. conjunctivitis and light sensitivity are associated with rubeola (measles), not rubella. kopek spots are present with rubeola, not rubella.

A nurse is caring for an infant with phenylketonuria. What diet should the nurse anticipate will be prescribed by the healthcare provider? a. fat-free b. protein-enriched c. phenylalanine-free d. low-phenylalanine

d. low-phenylalanine rationale: because phenylalanine is an essential amino acid, it must be provided in quantities sufficient for the promotion of growth but low enough to maintain a safe blood level. phenylalanine is derived from protein, not fat. an enriched-protein diet contains increased amount of proteins, including phenylalanine, which should be ingested in limited amounts. because phenylalanine is an essential amino acid, it cannot be totally removed from the diet.

During an assessment, the nurse shines a light into the client's eyes and observes that the pupil remains dilated. Which cranial nerve (CN) does the nurse suspect to be affected? a. CN III b. CN V c. CN VII d. CN VIII

a. CN III rationale: CN III is the oculomotor nerve, which is responsible for pupillary constriction and accommodation. Damage to this nerve may result in failure of the pupils to constrict; this the pupils will remain dilated even upon exposure to a light source. CN V is the trigeminal nerve, which is responsible for chewing. CN VII is the facial nerve; asymmetrical facial movements indicate damage to this nerve. CN VIII is the vestibulocochlear nerve; decreased hearing acuity or hearing impairment or equilibrium impairment may indicate damage to CN VIII.

A nurse is assessing a 3-year-old child with a tentative diagnosis of lead poisoning. What clinical finding supports this diagnosis? a. epistaxis b. clumsiness c. excessive salivation d. decreased pulse rate

b. clumsiness rationale: behavioral disturbances such as clumsiness are important clues to early identification of lead poisoning. nosebleeds, excessive salivation, and bradycardia are not clinical signs of lead poisoning

imiquimod

beneficial treatment for genital warts in clients with HPV infections

A nurse is obtaining a health history from the parents of a preschooler with celiac disease. What characteristic does the nurse expect when the parents describe their child's stools? a. large, frothy, green b. small, pale, mucoid c. large, pale, foul-smelling d. moderate, green, foul-smelling

c. large, pale, foul-smelling rationale: children with celiac disease have a gluten-induced enteropathy and are unable to absorb fats from the intestinal tract, resulting in the typical characteristics of their stools. the stools are large and fatty or frothy, not mucoid. although the stools are large and frothy, they are pale because of their high fat content.

A nurse is caring for a 6-day-old preterm infant in the neonatal intensive care unit. What complications should the nurse be alert for in this infant? a. meconium ileus b. duodenal atresia c. imperforate anus d. necrotizing enterocolitis

d. necrotizing enterocolitis rationale: necrotizing enterocolitis (NEC) is an inflammatory disease of the GI mucosa that is related to several factors (e.g., prematurity, hypoxemia, high-solute feedings); it involves shouting of blood from the GI tract, decreased secretion of mucus, and increased growth of gas-forming bacteria, eventually resulting in obstruction. NEC usually manifests 4-10 days after birth. meconium ileus occurs within the first 24h when the newborn cannot pass any stool. it is not related to the development of NEC; it is a complication of CF. duodenal atresia is a congenital defect that occurs early in gestation and is present at birth. imperforate anus is an anorectal malformation that results in the absence of an external anal opening; it is present at birth.

A 6-year-old child comes to the school nurse reporting a sore throat, and the nurse verifies that the child has a fever and a red, inflamed throat. When a parent of the child arrives at school to take the child home, the nurse urges the parent to seek treatment. If the sore throat is not treated, what illness is of most concern to the nurse? a. tetanus b. influenza c. scarlet fever d. rheumatic fever

d. rheumatic fever rationale: the child's symptoms are suggestive of hemolytic streptococcus infection. rheumatic fever is an inflammatory disease involving the joints, heart, CNS, and subcutaneous tissue that can occur if the infection is not treated. it is tight to be an autoimmune process that causes connective tissue damage. tetanus is not caused by a streptococcal infection. this disorder described is not influenza or scarlet fever.

azithromycin

drug of choice for chlamydia

benzathine penicillin

drug of choice for pt with syphilis

a nurse is caring for a 2-year old child with meningitis. for which clinical manifestations of increasing intracranial pressure should the nurse assess the child? select all that apply. 1. seizures 2. vomiting 3. bulging fontanels 4. subnormal temperatues 5. decreased respiratory rate

1, 2, 5 rationale: irritation of the cerebral tissue can cause seizures. pressure on the vital centers can cause vomiting. pressure on the respiratory center results in a decreased respiratory rate. a 2-year old child's fontanels are closed, so bulging fontanels are not a sign of increased intracranial pressure in this case. the inflammatory process of meningitis causes an increase in temperature.

what does the tetralogy of Fallot consist of?

1. right ventricular hypertrophy 2. ventricular septal defect 3. patent ductus arteriosus 4. mitral insufficiency

A 9-year-old child is admitted to the pediatric unit with a tentative diagnosis of acute lymphocytic leukemia (ALL). What early signs and symptoms of leukemia does the nurse expect to identify? Select all that apply. 1. flushing 2. anorexia 3. limb pain 4. splenomegaly 5. mouth lesions

2, 3, 4 rationale: hyper metabolism associated with the leukemic process results in loss of appetite. bone marrow dysfunction and invasion of the periosteum result in bone pain. infiltration, enlargement, and fibrosis of the spleen occur early in the disease process as the excess WBCs are trapped. flushing is not expected. bone marrow dysfunction results in anemia, and pallor accompanies the decreased erythrocyte count. mouth lesions (stomatitis) occur later during the disease process or as a result of chemotherapy.

The nurse is caring for a preschooler diagnosed as suffering from frequent episodes of sleep terrors. Which statements describing the nature of sleep terrors does the nurse know to be true? Select all that apply. 1. it is followed by full waking. 2. it usually occurs 1-4 hours after falling asleep 3. it takes place during REM sleep 4. the child rapidly returns to sleep after an episode of sleep terrors 5. the child is aware of and reassured by another's presence after an episode of sleep terrors

2, 4 rationale: sleep terrors usually occur 1-4 hours after falling asleep, when non-REM sleep is deepest. after an episode, the child rapidly returns to sleep; it is often difficult to keep the child awake after this. nightmares are followed by full waking; sleep terrors are followed by partial arousal. nightmares take place during REM sleep; sleep terrors take place during state IV, non-REM sleep. after a nightmare, the child is aware of and and reassured by another person's presence, after an episode of sleep terrors, however, the child is not very aware of another's presence, is not comforted, and may push the person away and scream and thrash more if held or restrained.

A 6-month-old infant is admitted to the pediatric unit with severe diarrhea. What nursing assessment is most indicative of dehydration? a. shaving the head b. administering the prescribed sedative c. starting the prescribed intravenous infusion d. giving the child a simple explanation of the procedure

b. administering the prescribed sedative Rationale: A 15-month-old toddler will have difficulty complying with directions to remain still and may be extremely frightened by the equipment, so sedatives are usually prescribed. Shaving the head is not necessary; the head must remain still but need not be shaved. Starting the prescribed infusion is not necessary unless a contrast medium is being used. The child is too young to understand even a simple explanation of the procedure

A 3-year-old child is admitted to the pediatric unit with a hemoglobin level of 6.4 g/dL (64 mmol/L). What should the nurse's priority assessment be? a. manifestations of shock b. increased white cell count c. presence of hemoglobinuria d. signs of cardiac decompensation

d. signs of cardiac decompensation Rationale: Cardiac decompensation results because the heart attempts to maintain tissue oxygenation by increasing its workload. Shock occurs with hemorrhage because the body does not have time to adapt to the sudden loss of blood. With chronic anemia, compensatory mechanisms take over. An increased white blood cell count indicates infection; however, the data do not indicate the presence of an infection. Hemoglobin in the urine suggests hemolytic anemia. Although it is important to determine the cause of the anemia, this is not the priority.

Ceftriaxone

gonorrhea drug

isotretinoin (accutane)

oral agent most effective for treating severe cystic acne when condition is unresponsive to other treatments

29-41%

what is the expected hematocrit range for a 1 yr old infant?

A nurse in the pediatric clinic suspects that Reye syndrome is developing in a 9-year-old child. For which early signs of Reye syndrome should the nurse assess the child? Select all that apply. 1. diarrhea 2. jaundice 3. lethargy 4. vomiting 5. confusion

3, 4, 5 rationale: lethargy, intractable vomiting, and confusion are all early signs of Reye syndrome that reflect CNS involvement. diarrhea and jaundice are not early signs of Reye syndrome. Jaundice may occur later with extensive liver damage.

A 3-year-old child who has acute lymphoblastic leukemia is scheduled to receive cranial radiation. What should the nurse explain to the parents about radiation? a. it avoids the need for chemo b. it reduces the risk for systemic infection c. it limits metastasis to the lymphatic system d. it prevents CNS involvement

d. it prevents CNS involvement rationale: radiation is used to destroy leukemic cells in the brain because chemotherapeutic agents are inadequately absorbed through the BB barrier. chemo is required to treat the systemic leukemic process. radiation does not reduce the risk for infection. cranial radiation has no effect on the systemic leukemic process.