A nurse is caring for a pediatric client who is receiving pancreatic enzyme replacement therapy. Which nursing action measures the effectiveness of the therapy?
Monitoring the stool consistency.
Checking the pupillary reflex response.
Listening to breath sounds.
Auscultating the apical pulse rate.
The Correct Answer is A
Choice A rationale:
Monitoring the stool consistency is a crucial nursing action to assess the effectiveness of pancreatic enzyme replacement therapy. Patients with pancreatic insufficiency, such as those with cystic fibrosis, may have difficulty digesting fats properly. Improved stool consistency, specifically a reduction in greasy and foul-smelling stools, indicates that the pancreatic enzymes are aiding in fat digestion.
Choice B rationale:
Pupillary reflex response assessment is unrelated to pancreatic enzyme replacement therapy. It is more commonly performed to assess neurological status or the effects of medications affecting the autonomic nervous system.
Choice C rationale:
Listening to breath sounds is important for assessing respiratory status, but it does not directly reflect the effectiveness of pancreatic enzyme replacement therapy.
Choice D rationale:
Auscultating the apical pulse rate is a general assessment of cardiovascular function and does not provide information about the effectiveness of pancreatic enzyme replacement therapy.
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Related Questions
Correct Answer is B
Explanation
Weighing the patient's wet diapers prior to discarding them.
Choice A rationale:
Inserting an indwelling urinary catheter is invasive and not appropriate for a non-toilet-trained 2-year-old unless medically necessary.
Choice B rationale:
Weighing wet diapers is the most accurate way to measure urine output in a young child who isn't toilet trained. This method provides essential information for assessing hydration and kidney function.
Choice C rationale:
Sitting the patient on the bedpan every two hours is suitable for older children but may not be effective or tolerable for a 2-year-old.
Choice D rationale:
Applying a pediatric urine collection device is an option, but it might not be as accurate as weighing wet diapers and may cause discomfort for the child.
Correct Answer is B
Explanation
Choice A rationale:
The statement about an increased risk for developing obesity is accurate. However, this does not indicate a need for further education about Down syndrome, as obesity is a common concern in the general population as well.
Choice B rationale:
The statement about an increased risk for developing diabetes would indicate a need for further education. Individuals with Down syndrome are indeed at an elevated risk of developing diabetes, often in their early adulthood.
Choice C rationale:
The statement about an increased risk for developing cataracts is accurate. However, it is not a primary concern associated with Down syndrome in infancy.
Choice D rationale:
The statement about skeletal abnormalities is accurate. While individuals with Down syndrome can have certain skeletal features, this is not a critical concern during infancy.
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