The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
Each row must have one option selected.
Perform guided imagery.
Have one of the parents hold the baby.
Encourage the baby's mother to breastfeed the baby.
Request a prescription for an anti-inflammatory drug.
The Correct Answer is C
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate.
Each row must have one option selected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Collecting a urine sample to screen for protein is essential as proteinuria is a key indicator of preeclampsia, a condition characterized by high blood pressure and potential organ damage during pregnancy. Early detection is vital to manage the condition and prevent complications.
Choice B rationale
Asking about a history of delivering large babies (macrosomia) is not immediately relevant to the current symptoms of headache and elevated blood pressure, which are more indicative of hypertensive disorders rather than previous birth weights.
Choice C rationale
Examining the client for pedal edema is important but not the immediate priority. While edema can be associated with preeclampsia, the presence of proteinuria and elevated blood pressure are more critical indicators that need to be addressed first.
Choice D rationale
Establishing the frequency of headaches is useful information but not the immediate priority. The combination of an excruciating headache and elevated blood pressure necessitates a more urgent assessment for preeclampsia, starting with a urine sample for protein.
Correct Answer is B
Explanation
Choice A rationale
Diet cola, although refreshing, contains caffeine which can contribute to dehydration. For adolescents with sickle cell anemia, hydration is crucial to prevent sickle cell crises. Moreover, sodas generally offer no nutritional benefits.
Choice B rationale
Lemonade is a better choice as it is hydrating and provides fluids without caffeine. Proper hydration is vital for sickle cell patients to maintain blood volume and prevent the sickling of red blood cells. Additionally, lemonade can supply essential electrolytes.
Choice C rationale
Ice tea, similar to diet cola, contains caffeine which can exacerbate dehydration. Hydration is key for individuals with sickle cell anemia to avoid complications and maintain adequate blood flow.
Choice D rationale
Milkshake, while providing hydration, is high in fat and sugar, which can be counterproductive. It also lacks the electrolytes present in lemonade which are beneficial for maintaining fluid balance in the body.
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