Patients' care/ Intervention
A 4-year-old child is restricted to 600 mL/24 hr. What nursing intervention will best help the child cope with this limitation?
Offering the child at least 1 oz of fluid, served in a 1-oz medicine cup, each waking hour Rationale: Providing at least 1 oz of fluid per hour, served in a 1-oz medicine cup, allows the child to drink 30 mL of fluid (1-oz medicine cup) without long periods between drinks. This approach will provide a total of 480 mL with leeway to offer another ounce four times during waking hours, either at meal or snack times or if the child awakens during the night. When fluid is limited, a smaller amount should be apportioned to the sleeping hours. If the child is allowed to drink as much as is desired until the limit is reached, 15 to 20 hours might elapse before fluids will be permitted again. Although fluids can be limited more easily during sleeping hours, 12 hours without fluid is too long for a young child to tolerate.
Calcium disodium edetate (EDTA) chelation therapy injections for lead poisoning can cause local discomfort. What is the most appropriate nursing intervention to lessen the discomfort?
Administering the injection with a local anesthetic Rationale: A local anesthetic can lessen the pain that occurs with this deep intramuscular injection. A cool bath will prolong the discomfort by inducing vasoconstriction, which will slow the rate of absorption. Massaging the site will cause more discomfort because the area is tender. Movement will probably be difficult and will cause more discomfort.
How can a nurse teach a preschooler about medical interventions most effectively?
By initiating therapeutic play Rationale: Allowing the child opportunities to play with the equipment that is needed for care is a way to allay anxiety, release tension, and gain mastery. Demonstration may be useful, but it is not the interactive format needed by the preschooler. Preschoolers may not understand a verbal explanation. Diversional play may be useful at other times, but it is not the format needed by a preschooler who is trying to cope with intrusive procedures.
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia?
Placing the child in a private room, restricting ill visitors, and using strict handwashing techniques Rationale: Children with leukemia most often die of infection; a low neutrophil count is associated with myelosuppressant therapy. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion are not appropriate measures to prevent infection resulting from neutropenia; they are appropriate for treating the anemia. Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture are not appropriate measures to prevent infection resulting from neutropenia; they are more appropriate for preventing bleeding. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and providing frequent saline mouthwashes are not appropriate measures to prevent infection resulting from neutropenia; they are used to ease and treat stomatitis.
A 4-year-old child has been found to have Kawasaki disease and is to be treated with intravenous immunoglobulin (IVIG). Before administration of the IVIG, what action(s) should the nurse take? Select all that apply.
Start an intravenous line., Have the parents sign permission for blood product administration. Rationale: IVIG is administered intravenously, so an IV line would be required. Because IVIG is a blood product, the parents will need to sign the appropriate permission form. The child does not need to be on nothing-by-mouth status. A cardiac monitor is not required. Common side effects include headache and kidney issues. Shortness of breath and back pain may be reported. IVIG is not an antibiotic. The parents should be asked about reactions to previously administered blood products.
The nurse is planning care for a preschooler with Kawasaki disease. Which intervention should the nurse plan to implement?
Administering intravenous immune globulin (IVIG) as prescribed Rationale: Kawasaki disease is treated with high-dose IVIG in combination with aspirin to lower the risk of coronary artery abnormalities. A clinical manifestation of bilateral nonpurulent conjunctivitis occurs with Kawasaki disease, so the nurse should avoid bright overhead lights. Nursing care is focused on adequate hydration, so fluids should not be restricted and fruit juices are not contraindicated. Kawasaki disease is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. It is not an infectious disease, so antibiotics (penicillin) are not administered.
A 3-year-old child is admitted to the pediatric unit with a diagnosis of nephrotic syndrome. The child has ascites, oliguria, respirations of 40 breaths/min, and a recent weight gain of 10 lb. What nursing intervention may help ease the child's respiratory difficulty?
Ensuring bedrest in the low Fowler position Rationale: The low Fowler position decreases pressure on the diaphragm from the abdominal organs and the ascites, thereby increasing respiratory excursion. Frequent feedings may lead to fatigue and quickened respiration, which will further distress the child. Placing the child in a well-ventilated room will not alleviate the cause of the respiratory problem, which is pressure on the diaphragm from the ascites. Oxygen therapy is not necessary; the dyspnea results from pressure on the diaphragm, not lack of oxygen.
A 3½-year-old child is returned to the room after a cardiac catheterization. What is the priority nursing intervention after this procedure?
Monitoring the insertion site for bleeding Rationale: Postprocedure hemorrhage at the catheter insertion site is a life-threatening complication that may occur after cardiac catheterization because arterial blood is under pressure and the catheter has entered an artery. Rest should be encouraged. Flexion of the insertion site should be avoided for several hours to prevent disturbance of the clot. Also, the child may have a cardiac problem that causes an oxygen deficit. It is unnecessary to compare blood pressures in the extremities; the distal pulses are monitored. The blood pressure should not be unstable unless a problem has developed; fluids should be offered as prescribed.
A child recovering from a severe asthma attack is given oral prednisone 15 mg twice daily. What is the priority nursing intervention?
Preventing exposure of the child to infection Rationale: Prednisone reduces the child's resistance to certain infectious processes and, as an anti-inflammatory drug, masks infection. The child will self-limit activity depending on respiratory status. The eosinophil count is often consistently increased in children with asthma. The child will need adequate hydration to help loosen and expel mucus.
What is the most important nursing intervention for a 3-year-old child with a diagnosis of nephrotic syndrome?
Preventing infection Rationale: Infection is a constant threat because of a poor general state of nutrition, a tendency toward skin breakdown in edematous areas, corticosteroid therapy, and lowered immunoglobulin levels. Although intake of foods with high nutritional value should be encouraged, this is not the priority. Fluid monitoring is important in determining whether a fluid restriction is indicated. Bedrest may be needed for severe edema, but ambulation is preferred.
What nursing intervention best meets the developmental needs of hospitalized preschool-age children?
Providing materials for simulating activities Rationale: Preschool children engage in imitative, imaginative, and dramatic play, often using play to simulate household activities. Although some preschoolers try to read, most of them are not ready until they are 6 years old. Preschoolers engage in associative play with other children; they are not ready to learn the rules of a game. Although family visits should be encouraged, the family's presence is not needed to meet preschoolers' developmental needs because they are now able to tolerate separation better than when they were toddlers.
What gross motor skills should the nurse expect a developmentally appropriate 3-year-old child to perform? Select all that apply.
Standing on one foot for a few seconds, Alternating the feet when walking up stairs Rationale: Skipping on alternate feet is usually accomplished at 5 years of age. Riding a small bike requires balance that is not present until 4 or 5 years of age; the 3-year-old child usually can ride a tricycle. Standing on one foot can be expected; usually it is accomplished by 3 years of age. Children at 3 years of age are able to walk up the stairs by alternating the feet; they can also jump off the bottom step. Jumping rope by lifting both feet simultaneously is not accomplished until later in the school-age years.
A nurse is assessing a 4-year-old child. What age-appropriate language skills does the nurse expect the child to have fulfilled? Select all that apply.
Uses six- and eight-word sentences, Has a vocabulary of 150 to 200 words Rationale: Because of developing cognitive abilities, 4-year-old children can form six- to eight-word sentences. Because of expanded experiences and developing cognitive ability, the 4-year-old should have a vocabulary of approximately 150 to 200 words. The use of appropriate grammar does not develop until 9 to 12 years of age. By 5 to 6 years of age, children ask the definitions of new words; 4-year-olds have not yet achieved this level of development. By 4 to 5 years of age a child's speech is intelligible although sounds such as "ch," "th," "sh," "z," "r," and "l" are frequently imperfect.
