A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?

Encourage attachment.

Minimize crying.

Restrict oral intake.

Initiate range of motion.

Answer and Explanation

The Correct Answer is B

Minimize crying.

Choice A rationale:

Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.

Choice B rationale:

Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.

Choice C rationale:

Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.

Choice D rationale:

Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.

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Correct Answer is C

Explanation

Choice A rationale:

Misdiagnosis is unlikely since the glucose levels are improving, indicating a valid diagnosis.

Choice B rationale:

Insulin-producing cells don't regenerate in substantial amounts to normalize glucose levels within a month. This process takes longer.

Choice C rationale:

This choice correctly identifies the situation as a temporary improvement due to the remaining insulin-producing cells functioning better temporarily.

Choice D rationale:

Complete recovery is not likely in such a short time frame.

A. Have the child choose a place in his room for the dog where he can see it but it is beyond his reach. B. Tell the mother that it is all right to keep the dog with him. C. Suggest to the mother that she tell the child that she will bring the dog back after taking it home to wash it. D. Suggest to the mother that she choose a replacement from the stuffed animals in the playroom.

Correct Answer is A

Explanation

Choice A rationale:

Allowing the child to have the soiled stuffed dog within sight but out of reach respects his attachment to the comfort object while maintaining hygiene standards of the hospital environment. The child's emotional well-being is crucial, and separation from a beloved item during a hospital stay can be distressing. Placing the dog in view but inaccessible helps strike a balance between comfort and infection control.

Choice B rationale:

While the mother's desire to keep the dog with the child is understandable, infection control is a concern in a hospital setting. Allowing the soiled object to remain in close proximity could compromise the child's health.

Choice C rationale:

Suggesting that the mother take the dog home to wash it and bring it back later might cause unnecessary distress for the child, who may worry about being separated from the comfort object for an extended period.

Choice D rationale:

Choosing a replacement from the playroom's stuffed animals could be unsettling for the child, as his attachment is to his specific dog. The familiarity of his own toy is likely to provide more comfort during the hospitalization. .

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A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient newly diagnosed with insulin-dependent diabetes mellitus comes to the clinic one month after diagnosis. The mother tells the nurse, "My child is getting better. The glucose levels are almost normal and my child requires less insulin.". What is the most appropriate response by the nurse?

Correct Answer is C

Explanation

A 4-year-old patient with cystic fibrosis is hospitalized with an acute pulmonary exacerbation. When the patient is admitted, he is clutching a soiled, tattered, stuffed dog. His mother says, "He insisted on bringing the dog with him. It really is filthy.". Which nursing action is most appropriate?

Correct Answer is A

Explanation

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