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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Polyarthritis is a manifestation of rheumatic fever, but it is not the primary manifestation. The main manifestation is carditis, involving inflammation of the heart's valves and structures.
Choice B rationale:
Carditis is a hallmark manifestation of rheumatic fever. It involves inflammation of the heart's valves and structures, leading to murmurs and potential long-term cardiac damage.
Choice C rationale:
Janeway lesions are not associated with rheumatic fever. They are painless, small erythematous or hemorrhagic macules on the palms and soles, typically seen in infective endocarditis.
Choice D rationale:
Subcutaneous nodules are not a primary manifestation of rheumatic fever. These nodules, which are firm and nontender, may develop over bony prominences in cases of severe rheumatic fever.
Choice E rationale:
Cervical lymphadenopathy is not a characteristic manifestation of rheumatic fever. This type of lymphadenopathy is more commonly seen in infections or lymphatic malignancies.
Correct Answer is C
Explanation
Choice A rationale:
Waiting to discuss the surgery until the child asks specific questions might lead to increased anxiety as the child may be apprehensive about the surgery but unable to express their concerns.
Choice B rationale:
Setting aside an hour a day to talk about the child's feelings concerning the surgery can be overwhelming for a 5-year-old, potentially increasing anxiety and making the procedure seem more daunting.
Choice C rationale:
Reading the child a story about children of similar age who go to the hospital for surgery provides a developmentally appropriate approach. It helps the child understand the process through relatable characters, reducing fear and uncertainty about the upcoming experience.
Choice D rationale:
Having the child visit a family whose preschool child has just been discharged from the hospital might expose the child to unfamiliar situations, possibly leading to more confusion and anxiety.
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