Psych School-age Child Exam 3
Which statement made by the parent of a school-age child who has had a craniotomy for a brain tumor would warrant further exploration by the nurse? "I wonder how long it will be before she can ride her bike." "After this, I will never let her out of my sight again." "Her best friend is eager to see her; I hope she won't be upset." "I hope that she'll be able to go back to school soon."
"After this, I will never let her out of my sight again." Explanation: Parents of a child who has undergone neurosurgery can easily become overprotective. Yet, the parents must foster independence in the convalescing child. It is important for the child to resume age-appropriate activities, and parents play an important role in encouraging this. Statements about going back to school would be expected. Parents want the child to return to normal activities after a serious illness or injury as a sign that the child is doing well.
The nurse is assisting with spirometry testing for a 6-year-old child with asthma. What instruction is most important for the nurse to give the child to obtain an accurate reading? "Blow quickly into the mouthpiece using the pursed-lip method." "Breathe out as hard as possible, and then breathe in deeply." "You will only need to do this once, so give us your best effort." "Hold the mouthpiece loosely between your lips while performing the test."
"Breathe out as hard as possible, and then breathe in deeply." Explanation: Several readings will be taken, during which the child is encouraged to give their best performance each time. The child should form a tight seal around the mouthpiece, breathe out forcefully, and then breathe in deeply. A pursed-lip method is not used for spirometry.
A 9-year-old child is placed on a liquid preparation of ferrous sulfate for the treatment of iron deficiency anemia. The nurse is teaching the parents about the side effects of ferrous sulfate. Which of the following statements is the most appropriate information for the nurse to convey to the parents? "The child's stool pattern may increase in frequency." "Have the child take the medicine through a straw." "Watch the child for problems with gait or balance." "Be sure the child wears sunscreen while taking this medication."
"Have the child take the medicine through a straw." Explanation: Staining of the teeth is a common side effect when ferrous sulfate is taken in liquid form. Drinking from a straw helps minimize this. The other options are not side effects related to this particular medication.
Parents of a school-age child with asthma express concern about letting the child participate in sports. What will the nurse instruct the parents about the relationship between exercise and asthma? "Continuous activities such as jogging are less likely to trigger asthma than intermittent activities such as baseball." "Taking prophylactic medication before the activity can prevent asthma attacks, making exercise safer." "Choose sports that do not require a lot of energy expenditure, because your child has chronically low oxygen levels." "Asthma attacks are triggered by allergens that trigger bronchoconstriction, not by exercise."
"Taking prophylactic medication before the activity can prevent asthma attacks, making exercise safer." Explanation: Although exercise may trigger asthma attacks, the nurse should tell the parents that taking prophylactic asthma drugs before beginning the activity can prevent attacks, enabling the child to engage in most sports. Children with asthma are not chronically hypoxic and have normal airway function between exacerbations. To say asthma attacks are triggered by allergens but not exercise isn't appropriate, because asthma attacks may be triggered by various factors, including allergens, exercise, medications, upper respiratory tract infections, and psychological stress. Provided the asthma is under control, most children can participate in sports and other physical activities; in fact, they benefit from exercise. Activity restrictions actually hamper peer interaction, which is essential to the development of the school-age child. A child with asthma may tolerate intermittent activities better than continuous ones.
A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next? Administer the acetaminophen with codeine. Distract the child by giving him breakfast. Assess the child again in 1 hour. Instruct the child to take deep breaths and blow his pain away.
Administer the acetaminophen with codeine. Explanation: The nurse should administer the acetaminophen with codeine because the client indicates he is having pain. Although the child reports less severe pain, he is still experiencing pain. The nurse will also want the child to have less pain because he will need to be more active during the day. Assessing the child later will likely cause the pain to have increased and be more difficult to manage. While distraction is appropriate for short-term pain, such as from a needlestick or pain that the child might be able to manage himself, postoperative pain should be relieved with medication.
The nurse is teaching the parents of a 6-year-old child with a corneal scratch about application of an ophthalmic ointment. What will the nurse include in the teaching? Have the child dab the ointment into the eye. Apply the ointment to the corner of the eyes. Apply the ointment to the lower conjunctival sac. Apply the ointment to the upper conjunctival sac.
Apply the ointment to the lower conjunctival sac. Explanation: Ophthalmic ointment is best instilled in the lower conjunctival sac. Applying to corner of the eye or the upper conjunctival sac are incorrect applications, as is dabbing ointment into the eye.
A school-age child with leukemia is taking immunosuppressive drugs. What health maintenance recommendation should the nurse include in the teaching plan? Monitor the child's temperature at school. Stay away from other children. Avoid any live attenuated vaccines. Take daily vitamin and mineral supplements.
Avoid any live attenuated vaccines. Explanation: Children who are immunosuppressed should not receive any live attenuated vaccines. Clients who are immunosuppressed and are given live attenuated vaccines such as measles, mumps, rubella, and oral polio vaccine can develop severe forms of the diseases for which they are being immunized, which can result in death. Inactivated vaccines may be given if necessary, but the client is not able to adequately produce needed antibodies, and it is recommended that immunizations be delayed for 3 months after the immunosuppressive drugs have been discontinued. It is unnecessary to monitor the child's temperature at school unless the child shows symptoms of an illness. Vitamin and mineral supplements are not normally given in conjunction with immunosuppressive drugs. When the client is immunosuppressed, the client should avoid only persons who have an infection.
The school nurse is teaching caregivers of school-age children about prevention of rheumatic fever. What should be included? administer aspirin (acetylsalicylic acid) to control fever take antibiotics until the child feels better monitor for conjunctivitis with exudate take the child to a healthcare provider when strep throat is suspected
take the child to a healthcare provider when strep throat is suspected Explanation: Rheumatic fever is caused by untreated strep throat. Aspirin (acetylsalicylic acid) should not be given to children because of the risk of Reye syndrome. Conjunctivitis is not associated with rheumatic fever. Antibiotics should be taken until the prescription is gone.
Which intervention should the nurse perform for a child who is receiving chemotherapy and allopurinol? Give foods that are high in potassium. Limit foods that are high in natural sugar. Encourage a high fluid intake. Omit carbonated fluids.
Encourage a high fluid intake. Explanation: Destruction of malignant cells during chemotherapy produces large amounts of uric acid. The child's kidneys may not be able to eliminate the uric acid, and tubular obstruction from the crystals could result in renal failure and uremia. Allopurinol interrupts the process of purine degradation to reduce uric acid buildup. The child should be encouraged to increase fluid intake to further assist in eliminating uric acid.Carbonated fluids need not be omitted when allopurinol is administered.An intake of foods high in potassium is not necessary nor is limiting foods high in natural sugar.
A nurse is caring for a 9-year-old child who is shy and fearful. The nurse asks the child a question, but the child does not answer immediately. What is the best approach by the nurse to develop a therapeutic relationship with the child? Remain silent after asking a question. Use common clichés when asking questions. Tell the child the consequences of not answering. Explain the question with medical words.
Remain silent after asking a question. Explanation: Silence offers an opportunity for the child to answer spontaneously and cautiously. More information is usually forthcoming if the nurse gives the child the opportunity to respond. All other choices are could potentially interfere with communication in the pediatric population.
A 7-year-old child is brought to the clinic by a parent for a school physical. When the child is prepared for examination, which interventions should the nurse provide to ensure the child's comfort? Distract the child with bright colors. Explain the purpose of the equipment being used during the examination. Have the child take off all of their clothing and put on a client gown. Offer the option of the parent staying or remaining in the waiting room.
Explain the purpose of the equipment being used during the examination. Explanation: At this age in the early school-age years, the child is still comfortable with a parent's presence in the examination room and is not generally given the option. It is important for the child's comfort and to decrease anxiety to explain the use of each piece of equipment prior to using it. During the school-age years, the child should be allowed to keep their underpants on along with the gown. Gaining distraction with bright objects would be used for an infant.
A 12-year-old child has had a traumatic head injury from playing in a football game. He is admitted to the emergency department and transferred to the pediatric intensive care unit. He has an IV of dextrose 5% in water at 21 mL/h and nasal oxygen at 2 L/min. The nurse is assessing the child at the beginning of the shift (2300 hours) and reviews the accompanying Glasgow Coma Scale flow sheet. The nurse notes that the child responds to pain, is making incomprehensible sounds, and has abnormal flexion of the limbs. What should the nurse do first? Lower the head of the bed. Increase the rate of the IV infusion. Notify the health care provider (HCP). Increase the rate of nasal oxygen.
Notify the health care provider (HCP). Explanation: This client is experiencing neurologic changes consistent with increasing intracranial pressure (ICP). The nurse should first notify the HCP. The HCP may intubate the child to ensure a patent airway. The nurse should not lower the head of the bed as this will cause increased ICP. The nurse should ensure an adequate fluid balance. The HCP will likely prescribe hypertonic saline to draw fluid from the brain.
A parent says that her family will soon be traveling abroad and asks why the drinking water in many regions must be boiled. The nurse should explain that, in addition to various types of dysentery, contaminated drinking water is most commonly responsible for the transmission of which disease? poliomyelitis brucellosis typhoid fever yellow fever
typhoid fever Explanation: Water is the usual vehicle for spreading typhoid fever. Yellow fever is spread through insect bites. Brucellosis (undulant fever) is spread by contaminated cow's milk. Poliomyelitis is most probably spread through respiratory secretions.
A staff nurse on a pediatric unit has a four-client assignment. Which child should the nurse assess first? a 7-year-old child whose parent is waiting for discharge instructions an 8-year-old child admitted from the postanesthesia care unit who's reporting pain a 9-year-old child with a broken leg who wants help moving from the bed to the chair a 10-year-old child with asthma whose oxygen saturation levels are dropping
a 10-year-old child with asthma whose oxygen saturation levels are dropping Explanation: Decreasing oxygen saturation levels indicate difficulty breathing and increased work of breathing. Airway, breathing, and circulation always take priority. The children reporting pain and waiting for discharge instructions are not life-threatening situations and don't take priority because administration of pain medication and reviewing discharge instructions can be delegated to another registered nurse. Moving a client from the bed to the chair is also not a life-threatening situation and can be delegated to a nursing assistant.
Which child most needs a screening for scoliosis? a toddler with a diet low in calcium and vitamin D a preschooler entering kindergarten a preadolescent client at the beginning of a growth spurt the infant of a mother with no prenatal care
a preadolescent client at the beginning of a growth spurt Explanation: Preadolescents are at greatest risk for scoliosis because of the growth associated with this age group. Incidence is higher in girls than boys and increases during periods of rapid growth.
After teaching a child with leukemia about a scheduled bone marrow aspiration, the nurse determines that the teaching has been successful when the child identifies which place as the site for the aspiration? right lateral side of the right wrist middle of the chest distal end of the thigh back of the hipbone
back of the hipbone Explanation: Although bone marrow specimens may be obtained from various sites, the most commonly used site in children is the posterior iliac crest, the back of the hipbone. This area is close to the body's surface but removed from vital organs. The area is large, so specimens can easily be obtained. For infants, the proximal tibia and the posterior iliac crest are used. The middle of the chest or sternum is the usual site for bone marrow aspiration in an adult. The wrist, chest, and thigh are not sites from which to obtain bone marrow specimens.
In a family with a 7-year-old child with a chronic illness, which family members feel jealousy, resentment, embarrassment, shame, fear of becoming ill, and guilt at causing the illness? child with the illness grandparents siblings parents
siblings Explanation: When a brother or sister is ill, siblings frequently experience jealousy and resentment of the increased attention given to the ill child, embarrassment and shame, fear of becoming ill, and guilt at causing the illness. Parents may experience grieving, denial, overprotectiveness, rejection, and overcompensation. The ill child may regress to a previous developmental stage and feel anxiety, depression, and anger. Both the child's and the siblings' reactions are influenced by the parents' response. Grandparents may experience ambivalence, disappointment, and grief.
When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which possible source of infection? nonrefrigerated custard undercooked eggs unwashed fruit a pet canary
undercooked eggs Explanation: Diarrhea related to Salmonella bacilli is commonly spread by raw or undercooked fowl and eggs, pet turtles, and kittens. Food poisoning caused by Staphylococcus species is commonly spread by inadequately cooked or refrigerated custards, cream fillings, or mayonnaise. Psittacosis, a respiratory illness, may be spread by canaries. Contaminated, unwashed fruit is associated with typhoid fever (caused by Salmonella typhi), a disorder rarely seen in the United States and Canada.
A child newly diagnosed with rheumatic fever is to receive penicillin therapy. Which statement by the parents should lead the nurse to judge that the parents understand the teaching about penicillin as part of the treatment plan? "How long will it take for the penicillin to help relieve the joint discomfort?" "Our child should take the medication until the primary health care provider discontinues it." "We should give our child the medication after eating." "We need to also give these pills to our other children to prevent them from getting rheumatic fever."
"Our child should take the medication until the primary health care provider discontinues it." Explanation: Penicillin is given to children with rheumatic fever to eradicate the hemolytic streptococci that triggered the autoimmune response that causes the disease.Penicillin does not decrease joint pain.Prophylactic use of penicillin with siblings is not indicated.Penicillin should be given on an empty stomach.
The parents of a client with cystic fibrosis ask the nurse why supplemental pancreatic enzymes are needed. What is the best response by the nurse? "Pancreatic enzymes reduce abdominal distention and constipation." "Pancreatic enzymes help with the movement of waste products." "Pancreatic enzymes decrease mucus production within the intestinal system." "Pancreatic enzymes promote absorption of nutrients and fat."
"Pancreatic enzymes promote absorption of nutrients and fat." Explanation: Pancreatic enzymes are given to a client with cystic fibrosis to aid digestion of fat and protein. The enzymes do not decrease mucus accumulation or constipation, nor do they help with the movement of waste products.
A child brought to the hospital with ketoacidosis is to receive regular insulin via an IV infusion. Which IV solution should the nurse expect the primary care provider to prescribe initially? 2.5% dextrose 0.9% saline 5% dextrose 0.45% saline
0.9% saline Explanation: A child with ketoacidosis has elevated blood glucose levels. Therefore, the child should initially receive normal saline solution because it is isotonic and does not contain glucose. The child receives this solution until the blood glucose level approaches the normal range. The rate, or units given per hour, is based on the child's weight.Solutions of 0.45% saline, 2.5% dextrose, and 5% dextrose are not used because their glucose content would only further elevate the child's glucose levels.
A father who is very upset about something the staff nurse said to him is in his child's room yelling and saying he will take his child home. Which action by the nurse-manager would be most appropriate? Consult the social worker, who is familiar with this family. Notify the primary care provider that the father is taking the child home. Call the child's mother to let her know what the situation is. Ask the father to come to the conference room to discuss the problem.
Ask the father to come to the conference room to discuss the problem. Explanation: The situation needs to be defused immediately. Therefore, removal of the father from the child's room, such as to a conference room, is the best approach to resolve the situation.The primary care provider needs to be notified but not until after the nurse-manager has attempted resolution.Calling the social worker or the mother may be helpful after the situation is defused.
A school-age child is admitted to the hospital with newly diagnosed insulin-dependent diabetes mellitus. On admission at 1000, his blood glucose is 180 mg/dL (10 mmol/L). He receives 2 units of regular insulin subcutaneously at 1030. What should the nurse include in the plan of care? Begin IV administration of 5% dextrose in water at 1100. Encourage the child to drink at least 500 mL of a sugar-free clear liquid by 1130. Assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness. Carefully regulate an IV solution of normal saline and NPH insulin at 1230.
Assess the child beginning at 1230 for shakiness, feelings of anxiety, or decreased level of consciousness. Explanation: The onset of the action of regular insulin is 30 minutes to 1 hour. The peak action occurs in 2 to 4 hours. The child needs to be checked for a hypoglycemic reaction (shaking, feelings of anxiety, and decreased level of consciousness) 2 hours after the insulin is given. NPH insulin is not given in an IV solution. Only regular insulin is given through the IV route .It is not necessary to force fluids on the child. Because there is no information that indicates the child is unable to take fluids and foods by mouth, it is not necessary to give a dextrose solution at this time.
A parent brings her 6-year-old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A urinary tract infection (UTI) is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? Select all that apply. Provide instructions only to the parent, not the child. Assess the parent's understanding of UTI and its causes. Limit fluids for the next few days to decrease the frequency of urination. Tell the parent to have the child wipe the back to the front after voiding and defecation. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish.
Assess the parent's understanding of UTI and its causes. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. Explanation: Assessing the parent's understanding of UTI and its causes provides the nurse with a baseline for teaching. The full course of antibiotics must be taken to eradicate the organism and prevent recurrence, even if the child's signs and symptoms decrease. Fluids should be encouraged, not limited, to prevent urinary stasis and help flush the organism from the urinary tract. Instructions should be given at the child's level of comprehension to help the child better understand the treatment and promote compliance. The child should wipe from the front to the back, not back to front, to minimize the risk of contamination after elimination.
A school nurse assesses that an 8-year-old child is preoccupied with sexual comments and activities. The nurse is concerned that the child may have been sexually abused at home. What is the nurse's best response to this situation? Discuss the child's behavior with the parents. Advise the child that the inappropriate behavior must stop. Continue to observe the behavior of the child. Notify the local Child Protective Services.
Notify the local Child Protective Services. Explanation: If a nurse suspects abuse of any nature, it must be reported to the appropriate authorities, such as Child Protective Services. The other options are incorrect because they do not demonstrate the required action of the nurse in this situation.
A school-age child with glomerulonephritis reports a headache and blurred vision. What immediate action should the nurse take? Administer acetaminophen. Obtain the child's blood pressure. Notify the health care provider (HCP). Put the client to bed.
Obtain the child's blood pressure. Explanation: Hypertension occurs with acute glomerulonephritis. The symptoms of headache and blurred vision may indicate an elevated blood pressure. Hypertension in acute glomerulonephritis occurs due to the inability of the kidneys to remove fluid and sodium; the fluid is reabsorbed, causing fluid volume excess. The nurse must verify that these symptoms are due to hypertension. Calling the HCP before confirming the cause of the symptoms would not facilitate his treatment. Putting the client to bed may help treat an elevated blood pressure, but first the nurse must establish that high blood pressure is the cause of the symptoms. Administering acetaminophen for high blood pressure is not recommended.
A 4-year-old child is admitted for an appendectomy. What is the most appropriate way for the nurse to prepare the child for surgery? Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask. Show the child a video about the surgery. Show the child a visual analog scale (VAS) based on a scale from 0 to 10. Explain how to use a patient-controlled analgesia (PCA) pump for pain control.
Permit the child to play with the blood pressure cuff, electrocardiogram (ECG) pads, and a face mask. Explanation: The best way to teach a child about surgery is through play. The nurse can let the child handle the items that will be used for monitoring, such as the blood pressure cuff and the ECG pads. The child will become more familiar with the face masks he sees the surgical team wearing in the operating room after playing with one and wearing it before surgery. A child of this age-group does not understand detailed explanations of how to use equipment, such as a PCA, a VAS, or even a video. The pain scale that should be used for children is the FACES scale.
A school nurse is examining a student at an elementary school and notes vesicular lesions that ooze, forming crusts on the face and extremities. Which actions by the nurse are most appropriate? Cleansing the lesions with Dakin's solution. Sending the child home and encourage evaluation by physician. Contacting the child's physician due to possible scarlet fever. Contacting the health department regarding German measles outbreak.
Sending the child home and encourage evaluation by physician. Explanation: The nurse should send the child home due to possible impetigo and encourage the parents to have the child evaluated by the physician. Impetigo is contagious until the child has been on antibiotics for 24-48 hours, which is why the child should be sent home to be seen by the physician. Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most commonly on the face and extremities. Small red lesions on the trunk and in the skin folds are characteristic of scarlet fever. A discrete pink-red maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Cleansing the lesions with Dakin's solution is not appropriate.
A school nurse is examining a student at an elementary school and notes vesicular lesions that ooze, forming crusts on the face and extremities. Which actions by the nurse are most appropriate? Cleansing the lesions with Dakin's solution. Sending the child home and encourage evaluation by physician. Contacting the health department regarding German measles outbreak. Contacting the child's physician due to possible scarlet fever.
Sending the child home and encourage evaluation by physician. Explanation: The nurse should send the child home due to possible impetigo and encourage the parents to have the child evaluated by the physician. Impetigo is contagious until the child has been on antibiotics for 24-48 hours, which is why the child should be sent home to be seen by the physician. Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most commonly on the face and extremities. Small red lesions on the trunk and in the skin folds are characteristic of scarlet fever. A discrete pink-red maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Cleansing the lesions with Dakin's solution is not appropriate.
A school health nurse is teaching a group of 7-year-old girls about preventing urinary tract infections. What is the most appropriate education for the nurse to include in the teaching? Recommend that the girls wear lightweight nylon undergarments. Encourage the girls to drink cranberry juice throughout the day. Tell the girls to avoid bubble baths and other perfumed bath additives. Teach the girls to wipe from back to front after going to the bathroom.
Tell the girls to avoid bubble baths and other perfumed bath additives. Explanation: Avoiding bath additives that can irritate the urethra is recommended to avoid urinary tract infections in girls. Though there is some evidence cranberry juice can reduce bladder infections, it is not advised that children consume sugar-containing beverages throughout the day. Children should also drink water, not just juice. Young girls should be encouraged to wear cotton undergarments because they are breathable. Young girls need to wipe front to back to take germs away from the opening that leads to the urinary system and decrease the risk of developing urinary tract infections.
The nurse is assisting another member of the health care team who is placing a peripherally inserted central catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes that the other team member has contaminated a sterile glove. What should the nurse do next? Ask the family to leave before confronting the team member. Report the incident to the nursing unit manager. Tell the team member the glove is contaminated. Discuss the incident with the team member after the event.
Tell the team member the glove is contaminated. Explanation: It is the responsibility of all health care members to protect the client. The provider may honestly not have realized that the glove was contaminated. Therefore, the nurse needs to alert the provider to the situation. Waiting until after the procedure to address the problem puts the child at unnecessary risk for infection. Asking the parents to leave could invoke anxiety in both the child and the parents. Alerting the provider does not need to be confrontational. If done with a calm approach, the result is most likely to be gratitude instead of embarrassment.
A nurse is developing a plan of care with the parents of a school-age client diagnosed with a seizure disorder. What instructions should the nurse give the parents to promote the client's growth and development? There is potential for a learning disability and the child may need tutoring to reach her grade level. The child will likely have normal intelligence and be able to attend regular school. There will be problems associated with social stigma and parents should consider home-schooling. The child will need activity limitation and will be unable to perform as well as her peers.
The child will likely have normal intelligence and be able to attend regular school. Explanation: Most children who develop seizures after infancy are intellectually normal. A child with a seizure disorder needs the same experiences and opportunities to develop intellectual, emotional, and social abilities as any other child. Activity limitation is not needed. Learning disabilities are not associated with seizures. The child is able to attend public school, and social stigma is a rarity.
At the beginning of a shift, the nurse is assigned to care for four school-age children admitted that day due to an acute asthma exacerbation. Which children should the nurse assess first? child with an oxygen saturation of 95% and wheezing on auscultation child whose mother reports that the child sometimes forgets to take the inhalers child with a respiratory rate of 24 breaths/minute and wheezing child with oxygen saturation of 93% and no wheezing on auscultation
child with oxygen saturation of 93% and no wheezing on auscultation Explanation: No wheezing on auscultation is an indication that the child is not moving air in and out and is in respiratory distress when the oxygen saturation is 93%. A respiratory rate of 24 breaths/minute in an 8-year-old child is normal. An oxygen saturation of 95% and wheezing noted on auscultation is somewhat of a concern, possibly indicating that the child needs oxygen or needs to clear the airways. However, this finding is a lower priority than no wheezing on auscultation and an oxygen saturation of 93%. The child sometimes forgetting to take medication is a concern but an oxygen saturation level of 93% is a more immediate concern.
The nurse is caring for a child with hemophilia who is actively bleeding from the leg. What should the nurse apply to the site? ice bag with elevation of the leg twice a day direct pressure to the injured area continuously for 10 minutes ice to the injured leg area several times a day direct pressure, checking every few minutes to see if the bleeding has stopped
direct pressure to the injured area continuously for 10 minutes Explanation: For the child with hemophilia who is actively bleeding, the nurse should apply direct pressure to the injured area for 10 minutes continuously along with elevating the leg. The continuous application of direct pressure aids in stopping the bleeding. Elevating the leg reduces blood flow to the area, thereby minimizing the extent of blood loss. Although ice will cause local vasoconstriction and slow the bleeding, applying continuous direct pressure is essential.
A parent asks the nurse if the lesions around her child's mouth could be impetigo. What manifestations would verify the parent's suspicion? honey-colored crusts, vesicles, and reddish maculae on the skin increased warmth, intense redness, swelling, and firmness of the skin erythema and formation of pus around hair follicles macular erythema with a sandpaper-like texture of the skin
honey-colored crusts, vesicles, and reddish maculae on the skin Explanation: Impetigo presents as reddish macules that turn to vesicles, which then erupt and form honey-colored crusts. The lesions can be in any stage.Redness and formation of pus around follicles describes folliculitis.Cellulitis is described as being warm, intensely red, edematous, and firm.Macular eruption with a sandpaper-like texture describes staphylococcal scalded skin syndrome.
The nurse assists with conscious sedation of a school-age client undergoing a bone marrow biopsy. What is the nurse's most important responsibility during the procedure? recording the procedure administering the topical anesthetic keeping the parents informed monitoring the patient
monitoring the patient Explanation: During conscious sedation the client may lose protective reflexes and adequate respiratory and cardiac function may be impaired. At every procedure there must be one health care professional whose sole responsibility is to monitor the client. Topical agents must be given in advance of the procedure to be effective. During the procedure, the nurse would not leave the child to speak with the parents. While the procedure would be documented according to the facility's protocols, proper monitoring of the client is the intervention most associated with reducing risks.
A child with leukemia has petechiae; gums, lips, and nose that bleed easily; and bruising on various parts of her body. Which laboratory test results should the nurse correlate with these findings? partial thromboplastin time of 38 seconds fibrinogen level of 75 mg/dL (2.21 µmol/L) serum calcium level of 5 mg/dL(1.25 mmol/L) platelet count of 80 x 103/mm3 (80 X 109/L)
platelet count of 80 x 103/mm3 (80 X 109/L) Explanation: In leukemia, megakaryocytes, from which platelets are derived, are decreased. Normal platelet counts range from 150 to 300 × 103/mm3 (150 to 300 X 109/L). A platelet count of 80 × 103/mm3 (80 X 109/L) is low, predisposing the child to bruising and bleeding easily.Although the serum calcium level is decreased, low serum calcium levels are not related to bleeding and bruising in a child with leukemia or any aspect of leukemia.Normal fibrinogen levels range from 200 to 400 mg/dL (5.9 to 11.8 µmol/L). However, insufficient fibrinogen concentration is not related to bleeding and bruising in a child with leukemia or any aspect of leukemia.Partial thromboplastin time (PTT), a measurement of clotting factors (except factor XIII), normally ranges from 25 to 40 seconds. The child's PTT is within the normal range.
A school-age client is admitted to the facility with a diagnosis of acute lymphocytic leukemia (ALL). The nurse formulates a nursing diagnosis of Risk for infection. What is the most effective way for the nurse to reduce the client's risk of infection? requiring staff and visitors to wear masks implementing reverse isolation maintaining standard precautions practicing thorough hand washing
practicing thorough hand washing Explanation: Both ALL and its treatment cause immunosuppression. Therefore, thorough hand washing is the single most effective way to prevent infection in an immunosuppressed client. Reverse isolation doesn't significantly reduce the incidence of infection in immunosuppressed clients; furthermore, isolation may cause psychological stress. Standard precautions are intended mainly to protect caregivers from contact with infectious matter, not to reduce the client's risk of infection. Staff and others needn't wear masks when visiting because most infections are transmitted by direct contact. Instead of relying on masks and other barrier methods, the nurse should keep persons with known infections out of the client's room.
A client is admitted to the emergency department with abdominal pain. The client's caregiver states the pain began about 12 hours ago. The nurse notes the client has a temperature of 100.8° F (38.2° C) and nausea. The client vomited once. Which abdominal area would be most appropriate for the nurse to assess? left upper abdominal quadrant left lower abdominal quadrant right upper abdominal quadrant right lower abdominal quadrant
right lower abdominal quadrant Explanation: The client's symptoms indicate appendicitis. Therefore, the nurse should assess the right lower abdominal quadrant. left lower abdominal quadrant to detect descending and sigmoid colon problems; right upper quadrant to detect gallbladder disease left upper quadrant to detect pancreatitis.
