Which client on an acute care pediatric unit requires the nurse’s immediate attention?

An 18-month-old client who had a cleft palate repair and is crying in pain.

A 12-year-old client who had an appendectomy and refuses to ambulate.

An 8-year-old client who had a tonsillectomy and is swallowing frequently.

A 15-year-old client who has an IV infusion and reports pain at the insertion site.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient’s health.
Choice B rationale
A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient’s health.
Choice C rationale
Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention.
Choice D rationale
While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient’s health.

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale
Cold compresses can help relieve joint pain associated with juvenile idiopathic arthritis. Cold therapy can reduce inflammation and numb the affected area, providing temporary relief.
Choice B rationale
This is incorrect. Ibuprofen should not be taken on an empty stomach because it can cause stomach upset or even lead to ulcers or bleeding. It is generally recommended to take ibuprofen with food or milk.
Choice C rationale
Performing range of motion exercises can help maintain joint flexibility and muscle strength in children with juvenile idiopathic arthritis. Regular exercise can also improve overall physical function and well-being.
Choice D rationale
While homeschooling may be a consideration for some families, it is not a general recommendation for all children with juvenile idiopathic arthritis. Many children with this condition can attend regular school with some accommodations as needed.
Choice E rationale
This is correct. Providing extra time for completion of activities of daily living (ADLs) can help children with juvenile idiopathic arthritis manage their symptoms and maintain their independence. It is important to allow children to perform tasks at their own pace to avoid causing unnecessary pain or fatigue.

A. “Bring your infant into the clinic today to be seen.”. B. “Burp your child more frequently during feedings.”. C. “Give your infant an oral rehydrating solution.”. D. “You might want to try switching to a different formula.”.

Correct Answer is A

Explanation

Choice A rationale
The symptoms described by the parent - projectile vomiting followed by hunger - could indicate a serious condition such as pyloric stenosis, which is a narrowing of the opening from the stomach to the small intestine. This condition can lead to severe dehydration and requires immediate medical attention.
Choice B rationale
While burping can help to relieve gas and minor stomach discomfort, it would not address the underlying issue causing the projectile vomiting. This advice might be appropriate for a baby with simple colic or gas, but not for the symptoms described.
Choice C rationale
While oral rehydrating solutions can help to replace lost fluids and electrolytes, they do not address the underlying cause of the projectile vomiting. Furthermore, if the baby is vomiting frequently, they may not be able to keep down the solution.
Choice D rationale
Switching formulas can sometimes help babies who have allergies or intolerances to certain ingredients in their current formula. However, the symptoms described are not typical of a formula intolerance or allergy. Moreover, switching formulas without seeking medical advice can potentially lead to other complications.

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Which client on an acute care pediatric unit requires the nurse’s immediate attention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a school-age child who has juvenile idiopathic arthritis. Which of the following home care actions should the nurse recommend? (Select all that apply)

Correct Answer is ["A","C","E"]

Explanation

A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?

A nurse in an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler?

A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response?

A nurse is planning care for a child who has severe diarrhea. Which of the following actions is the nurse’s priority?

What is the mode of transmission for Tinea Capitis (ringworm)?

A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. Which of the following instructions should the nurse give the parent?

A child has had a cast placed on his left arm following a diagnosed fracture. Which actions should the nurse take? (Select all that apply)

A nurse is providing teaching to a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates a need for additional teaching?