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A nurse in an emergency department is caring for a school-age child.

Exhibits

The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

Maintain NPO status.

Administer an antipyretic.

Initiate an infusion of IV fluids.

Administer a cleansing enema.

Prepare child and parents for ostomy placement.

Educate child and parents about plan of care.

Administer an analgesic.

Administer antibiotics.

Answer and Explanation

Correct Answer : A,B,C,F,G,H

A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

Cough

Hypertrophic Pyloric Stenosis: Pyloric stenosis typically causes forceful vomiting but does not cause coughing.
Gastroesophageal Reflux: Coughing can occur due to aspiration or irritation of the esophagus.

Recurrent Emesis

Hypertrophic Pyloric Stenosis: Projectile vomiting after feedings is a hallmark sign of pyloric stenosis.
Gastroesophageal Reflux: GER can also cause recurrent vomiting, though it is usually less forceful than in pyloric stenosis.

Inadequate Weight Gain

Hypertrophic Pyloric Stenosis: The inability to retain feedings can lead to poor weight gain.
Gastroesophageal Reflux: Reflux can also result in poor weight gain if feedings are frequently vomited.

Irritability

Hypertrophic Pyloric Stenosis: Hunger due to inadequate feeding can cause irritability.
Gastroesophageal Reflux: Discomfort from esophageal irritation can lead to irritability.

A. Maintain aseptic technique during the child's dressing changes. B. Provide low-calorie snacks for the child several times each day. C. Apply continuous passive motion devices to the child's lower extremities during periods of rest. D. Administer pain medication to the child 30 min following physical therapy.

Correct Answer is A

Explanation

A. "Maintain aseptic technique during the child's dressing changes." Aseptic technique reduces the risk of infection, which is critical for children with burns as their immune response may be compromised.
B. "Provide low-calorie snacks for the child several times each day." Children with burns require a high-calorie, high-protein diet to promote healing and compensate for increased metabolic demands.
C. "Apply continuous passive motion devices to the child's lower extremities during periods of rest." Passive motion devices are not typically indicated for burn injuries unless there is joint involvement requiring physical therapy for mobility restoration.
D. "Administer pain medication to the child 30 min following physical therapy." Pain medication should be administered before physical therapy to improve tolerance and participation.

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A nurse in an emergency department is caring for a school-age child. Exhibits The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 4-month-old infant in the outpatient setting. Exhibits For each assessment finding, click to specify if the finding is consistent with hypertrophic pyloric stenosis or gastroesophageal reflux. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"A,B"}}

Explanation

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A nurse in an emergency department is caring for a school-age child.

Exhibits

The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.