NCLEX Practice Exam for Pediatric Nursing 1

EXPLANATION

✔Correct answer:

Gently swab mycostatin directly onto the areas affected by thrush. Mycostatin (nystatin) is an antifungal medication used to treat oral thrush, an infection caused by the yeast Candida albicans. For it to be most effective, it needs to come into direct contact with the affected mucosal areas in the mouth. By gently swabbing the medication directly onto the areas affected by thrush, Nurse Reynolds ensures that the medication is applied precisely where it is needed to treat the infection.

Oral thrush presents as white patches on the mucous membranes of the mouth. Effective treatment requires direct application of the antifungal agent to these areas to eradicate the yeast and reduce symptoms.

Think of treating oral thrush like cleaning a spot on a window. To remove the spot effectively, you need to apply the cleaner directly to the dirty area rather than just spraying it in the general direction of the window.

Nurses should educate caregivers on how to apply mycostatin properly to ensure the medication's effectiveness and provide comfort to the infant.

• Ensure hands are washed thoroughly before and after administering the medication.
• Use a clean, soft applicator or swab to apply the mycostatin directly to the white patches in the mouth.
• Administer the medication after feeding to allow the medication to remain in contact with the affected areas for a longer duration.
• Instruct caregivers to avoid feeding or giving water immediately after administering the medication to ensure it is not washed away.
• Monitor the infant for improvement and any potential side effects.

✘Incorrect answer options:

First give the infant water to drink, then administer the mycostatin using a syringe. This method may dilute the medication, reducing its effectiveness by not allowing it to stay in direct contact with the affected areas long enough.

Apply mycostatin onto the nipple of a feeding bottle and let the infant suck it. While this might seem practical, it does not ensure that the medication will adequately cover all the affected areas in the mouth.

Combine mycostatin with the infant's formula. Mixing the medication with formula can dilute its concentration and reduce its effectiveness, as it may not adequately contact the thrush patches.

EXPLANATION

✔Correct answer:

Every 2 hours. In the initial period following the application of Buck's traction, it is essential to frequently assess the patient's circulation, sensation, and movement (CSM) to promptly identify any signs of neurovascular compromise. Monitoring every 2 hours allows for timely detection and intervention of potential complications such as impaired circulation, nerve damage, or pressure sores. Frequent checks help ensure that the traction is properly aligned and not causing any undue pressure or damage to the patient's leg.

Buck's traction is used to stabilize and immobilize fractures, reduce muscle spasms, and alleviate pain. However, the application of traction can affect neurovascular status by exerting pressure on nerves and blood vessels. Frequent monitoring of CSM is crucial to detect and address any issues early.

Think of monitoring the patient's leg in traction like checking on a new plant. Initially, it needs frequent watering and care to ensure it grows properly. Similarly, the patient's leg needs frequent checks to ensure proper circulation and function, especially right after traction is applied.

Nurse Cooper should conduct thorough and frequent CSM checks initially and then adjust the frequency as per the institution's policy and the patient's condition.

• Perform CSM checks every 2 hours initially after the application of traction.
• Assess the color, temperature, capillary refill, pulses, sensation, and movement of the affected limb.
• Document findings meticulously and report any abnormalities immediately to the healthcare provider.
• After the initial critical period, adjust the frequency of CSM checks based on the patient’s stability and the healthcare provider's orders.
• Educate the patient about signs of neurovascular compromise to report, such as increased pain, numbness, tingling, or decreased movement.

✘Incorrect answer options:

Every 4 hours. While this frequency might be appropriate for a stable patient later on, it is not sufficient immediately after applying traction, as complications can arise quickly and need prompt identification and intervention.

Every 8 hours. This is far too infrequent for a patient in traction, where the risk of neurovascular compromise necessitates much more frequent monitoring.

Once per shift. Checking CSM only once per shift would not provide the necessary monitoring frequency required to detect early signs of complications.

EXPLANATION

✔Correct answer:

The average blood glucose levels over the past few months. The glycosylated hemoglobin (HbA1c) test is used to measure the average blood glucose levels over the past two to three months. Hemoglobin is a protein in red blood cells that carries oxygen. When glucose attaches to hemoglobin, it forms glycosylated hemoglobin. The HbA1c test measures the percentage of hemoglobin that is coated with glucose. Since red blood cells live for about three months, this test provides a long-term indication of blood glucose control, making it a crucial tool for managing diabetes.

The HbA1c level reflects the amount of glucose that has bound to hemoglobin in red blood cells. Higher levels of blood glucose result in higher levels of glycosylated hemoglobin. This test is important for monitoring how well a patient's blood sugar is being controlled over time, rather than just at the moment of testing.

Think of the HbA1c test like checking the average speed of a car over a long trip. Rather than looking at the speed at one specific moment, it provides an overview of how fast the car has been going on average throughout the journey.

Nurse Martinez should educate the patient on the significance of the HbA1c test results and how they relate to the overall management of diabetes.

• Explain that the HbA1c test reflects average blood glucose levels over the past two to three months.
• Discuss the target HbA1c levels as recommended by their healthcare provider, usually below 7% for many diabetics, but individualized based on the patient's health status and treatment goals.
• Reinforce the importance of maintaining consistent blood glucose control to prevent complications associated with diabetes.
• Encourage adherence to medication, diet, and exercise regimens as key components in managing blood glucose levels effectively.
• Address any questions or concerns the patient may have about the test or their diabetes management plan.

✘Incorrect answer options:

The current level of insulin in her bloodstream. The HbA1c test does not measure insulin levels. Insulin levels are assessed through other specific tests, such as fasting insulin tests.

Her typical blood sugar level when fasting. Fasting blood sugar levels are measured using a fasting blood glucose test, not the HbA1c test. The HbA1c provides a longer-term average rather than a snapshot of glucose levels at a single point in time.

The peak blood sugar level she has reached in the past week. The HbA1c test does not provide information on the highest blood sugar levels over a short period. It reflects the average over a longer period, covering approximately two to three months.

EXPLANATION

✔Correct answer:

Reduced mean corpuscular volume (MCV). Iron deficiency anemia is characterized by a reduction in the size of red blood cells (microcytosis), which is reflected in a decreased mean corpuscular volume (MCV). The MCV measures the average size of red blood cells, and in iron deficiency anemia, these cells are typically smaller than normal due to insufficient hemoglobin production. This reduction in size is a key indicator of microcytic anemia, which is commonly caused by iron deficiency.

Iron is a crucial component of hemoglobin, the molecule that carries oxygen in red blood cells. When there is a deficiency of iron, hemoglobin production decreases, resulting in smaller and less effective red blood cells. This leads to the characteristic findings of microcytic, hypochromic anemia.

Imagine red blood cells as delivery trucks carrying oxygen. In iron deficiency anemia, the trucks (red blood cells) are smaller because they don’t have enough cargo space (hemoglobin) to carry a full load of oxygen. This is why the MCV, which measures the size of the trucks, is reduced.

Nurse Wilson should ensure that the child receives appropriate treatment for iron deficiency anemia, which may include iron supplementation and dietary changes to increase iron intake. Monitoring and follow-up blood tests are essential to assess the response to treatment.

• Administer prescribed iron supplements and educate the parents on proper administration (e.g., giving supplements with vitamin C-rich foods to enhance absorption).
• Encourage dietary changes to include iron-rich foods such as lean meats, beans, lentils, fortified cereals, and leafy green vegetables.
• Monitor for side effects of iron supplementation, such as gastrointestinal discomfort or constipation.
• Schedule follow-up appointments to recheck hemoglobin and MCV levels to evaluate the effectiveness of the treatment.
• Educate the family on the importance of adherence to treatment and dietary recommendations to prevent recurrence of anemia.

✘Incorrect answer options:

Hematocrit levels within the normal range. Hematocrit levels are usually decreased in iron deficiency anemia because they reflect the proportion of red blood cells in the blood. Normal hematocrit levels would not be consistent with iron deficiency anemia.

Total iron-binding capacity (TIBC) within the normal range. TIBC is often elevated in iron deficiency anemia as the body increases the production of transferrin to maximize iron transport. A normal TIBC would not be typical in this condition.

Elevated levels of hemoglobin. Elevated hemoglobin levels are not indicative of iron deficiency anemia. In fact, hemoglobin levels are typically reduced in this condition due to insufficient iron for hemoglobin synthesis.

EXPLANATION

✔Correct answer:

Playing in a park that's near heavy traffic with many vehicles passing by. Lead poisoning in children is often associated with exposure to environmental sources of lead. One significant source is air and soil contamination from vehicle emissions, particularly in areas with heavy traffic. Although the use of leaded gasoline has decreased significantly, older vehicles and industrial emissions can still contribute to lead contamination in nearby soil and dust. Children playing in these environments may be exposed to lead through inhalation or ingestion of contaminated dust and soil.

Lead poisoning occurs when lead builds up in the body over time, often from repeated exposure to small amounts of lead. Children are especially vulnerable because their bodies absorb lead more easily, and their developing nervous systems are more sensitive to its harmful effects. Lead can cause serious health issues, including cognitive impairment, developmental delays, and behavioral problems.

Imagine a sponge (the child's body) absorbing water (lead). In a heavily trafficked area, there are many tiny drops of water (particles of lead) that the sponge can soak up over time, leading to it becoming saturated with water (lead poisoning).

Nurse Mitchell should educate the community about the risks of playing near high-traffic areas and recommend measures to reduce exposure to lead.

• Encourage parents to monitor and limit their children's playtime in areas close to heavy traffic or industrial sites.
• Advise regular handwashing, especially before eating, to reduce the ingestion of lead-contaminated dust.
• Recommend routine cleaning of floors, windowsills, and other surfaces to minimize dust accumulation in homes.
• Suggest frequent washing of toys and pacifiers to reduce lead dust ingestion.
• Promote a balanced diet rich in iron, calcium, and vitamin C, which can help decrease lead absorption in the body.

✘Incorrect answer options:

Engaging in play with sand in the park. While sand in parks could potentially be contaminated with lead, it is generally not as significant a risk as areas near heavy traffic. Sand in public parks is often maintained and monitored for safety.

Playing with plastic balls alongside other children. Plastic balls used in children's play are typically made from non-toxic materials and are unlikely to be a significant source of lead exposure.

Spending time playing with stuffed toys at home. Stuffed toys are generally safe and do not pose a lead exposure risk unless they have been in contact with contaminated dust or paint. Regular cleaning of toys can help ensure they remain safe for children.

EXPLANATION

✔Correct answer:

Glucose-6-phosphate dehydrogenase deficiency (G6PD). G6PD deficiency is an X-linked recessive genetic disorder that affects the enzyme glucose-6-phosphate dehydrogenase. This enzyme plays a critical role in the pentose phosphate pathway, which helps protect red blood cells (RBCs) from oxidative damage. When individuals with G6PD deficiency are exposed to certain triggers such as infections, certain medications, or fava beans, their RBCs can undergo oxidative stress leading to hemolysis, or the premature destruction of RBCs. This condition is more common in males and can lead to episodes of hemolytic anemia, characterized by jaundice, dark urine, fatigue, and pallor.

G6PD deficiency impairs the ability of red blood cells to produce NADPH, a molecule that helps protect cells from oxidative damage. Without sufficient NADPH, RBCs are vulnerable to oxidative stress, leading to their destruction.

Think of RBCs as balloons. Normally, they have a protective coating (NADPH) that prevents them from popping. In G6PD deficiency, this protective coating is weak or missing, making the balloons more likely to burst (hemolyze) when exposed to certain stressors.

Nurse Davis should ensure that patients with G6PD deficiency and their families are educated about the condition, including potential triggers and signs of hemolysis. Regular monitoring and avoidance of known triggers are essential.

• Educate the patient and family about the condition and the importance of avoiding triggers such as certain foods (fava beans), medications (sulfa drugs, certain antibiotics), and infections.
• Advise regular follow-ups and blood tests to monitor hemoglobin levels and overall health.
• Ensure the patient wears a medical alert bracelet indicating their condition.
• Provide information on managing acute hemolytic episodes, including hydration, rest, and seeking medical attention if symptoms worsen.

✘Incorrect answer options:

Homocystinuria. This is an inborn error of metabolism that affects the body's ability to process the amino acid methionine, leading to an accumulation of homocysteine. It can cause various complications, including developmental delays and cardiovascular problems, but it does not typically cause hemolysis of RBCs.

Phenylketonuria. This is a genetic disorder that affects the metabolism of the amino acid phenylalanine, leading to its buildup in the body. It primarily affects the brain and can cause intellectual disability if not managed through dietary restrictions, but it does not cause hemolysis of RBCs.

Celiac Disease. This is an autoimmune disorder triggered by the ingestion of gluten, leading to damage in the small intestine. It affects nutrient absorption but does not cause premature destruction of RBCs.

EXPLANATION

✔Correct answer:

Lumbar puncture. A lumbar puncture (also known as a spinal tap) is the definitive diagnostic procedure for meningitis. It involves collecting cerebrospinal fluid (CSF) from the spinal canal to analyze for the presence of infectious agents, white blood cells, glucose levels, and proteins. These analyses help confirm the diagnosis of meningitis, determine its cause (bacterial, viral, fungal, or other), and guide appropriate treatment. Symptoms such as nuchal rigidity (neck stiffness), fever, vomiting, and lethargy are classic signs of meningitis, making lumbar puncture a critical step in the diagnostic process.

Meningitis involves the inflammation of the protective membranes covering the brain and spinal cord, known as the meninges. This inflammation can lead to increased intracranial pressure and other serious complications. Identifying the specific pathogen through CSF analysis is crucial for targeted therapy.

Think of a lumbar puncture like testing the water in a pond to identify the cause of pollution. Just as water testing can reveal contaminants, a lumbar puncture can detect pathogens and other abnormalities in the cerebrospinal fluid.

Nurse Daniels should prepare the patient and family for the lumbar puncture procedure by explaining its purpose, what to expect, and how it will help in diagnosing and treating the condition.

• Explain the procedure to the patient and family, addressing any concerns and ensuring informed consent is obtained.
• Assist the patient in maintaining the correct position for the lumbar puncture, typically lying on their side with knees drawn up to the chest or sitting and leaning forward.
• Monitor the patient’s vital signs before, during, and after the procedure.
• Observe for any post-procedure complications, such as headache or signs of infection at the puncture site.
• Provide post-procedure care instructions, including the importance of lying flat for a period of time to reduce the risk of post-lumbar puncture headache.

✘Incorrect answer options:

Throat and ear culture. While these cultures can help identify sources of infection in cases of respiratory or ear infections, they are not specific or sufficient for diagnosing meningitis.

Blood culture. Blood cultures can identify systemic infections and are often performed in cases of suspected sepsis, but they are not definitive for diagnosing meningitis. They can be used as a supplementary test.

Computed Tomography (CT) scan. A CT scan can be useful to rule out other conditions or complications before a lumbar puncture, especially if there is concern for increased intracranial pressure or mass effect. However, it is not the primary diagnostic tool for confirming meningitis.

EXPLANATION

✔Correct answer:

The newborn's heart rate is measured at 80 beats per minute. A newborn's heart rate is typically between 120 to 160 beats per minute when awake and calm. A heart rate of 80 beats per minute is significantly lower than the normal range and could indicate a condition known as bradycardia, which may require further medical evaluation to rule out underlying issues such as hypoxia, congenital heart defects, or other complications.

Think of the newborn's heart rate like the engine of a car. If the engine is running too slowly, the car might not perform well and could indicate a problem that needs to be checked out immediately.

Nurse Andrews should promptly report this abnormal finding to the attending pediatrician or neonatologist for further assessment and potential intervention. Continuous monitoring and possibly additional diagnostic tests would be necessary to determine the cause and appropriate treatment.

• Immediately notify the pediatric team of the abnormal heart rate.
• Monitor the newborn’s vital signs closely, including oxygen saturation and respiratory rate.
• Prepare for potential resuscitative measures if the heart rate continues to remain low or if other signs of distress appear.
• Document all findings and interventions accurately and promptly.
• Provide reassurance and information to the parents, explaining the situation and the steps being taken to ensure their newborn's health.

✘Incorrect answer options:

The newborn's breathing is irregular and abdominal, ranging between 30-60 breaths per minute. This is a normal finding. Newborns often exhibit irregular and abdominal breathing patterns, and a respiratory rate between 30-60 breaths per minute is typical.

The newborn's head shape appears uneven, also known as molding. Molding is a common and normal occurrence in newborns delivered vaginally, caused by the pressure exerted on the baby's head during passage through the birth canal. It usually resolves on its own within a few days to weeks.

The newborn exhibits a positive Moro (startle) reflex. The Moro reflex is a normal primitive reflex in newborns, where they extend their arms and legs, then retract them in response to a sudden loss of support or a loud noise. This reflex typically disappears by 4 to 6 months of age.

EXPLANATION

✔Correct answer:

The child is unable to sit without support. By the age of 9 months, most infants have developed the motor skills necessary to sit without support. This milestone is important as it indicates proper neuromuscular development and muscle strength. An inability to sit independently at this age could be a sign of developmental delay or an underlying neuromuscular disorder, and it warrants further evaluation by a healthcare provider.

Sitting independently involves the coordination of various muscle groups and the integration of motor skills developed over the first few months of life. Delays in achieving this milestone may suggest issues with muscle tone, strength, or neuromotor coordination, potentially indicating conditions such as hypotonia, cerebral palsy, or other developmental disorders.

Think of a baby learning to sit as similar to learning to balance on a bicycle. Initially, the child needs support and practice to develop the balance and strength necessary to sit independently, just as a person learning to ride a bike might need training wheels and practice.

Nurse Taylor should take note of the developmental delay and discuss it with the parents, recommending further evaluation by a pediatrician or a specialist in pediatric neurology or developmental medicine.

• Document the findings and communicate the concern to the pediatrician.
• Discuss the child's developmental milestones with the parents and provide reassurance while explaining the importance of early intervention.
• Recommend a referral for a developmental assessment to identify any underlying issues.
• Provide resources and support for early intervention services, such as physical therapy if appropriate.
• Follow up on the child's progress and ensure regular check-ups to monitor development.

✘Incorrect answer options:

The baby exhibits distress (crying) when the mother leaves the room. This is a normal behavior known as separation anxiety, which typically begins around 6 to 9 months of age and indicates healthy attachment and emotional development.

The baby is unable to vocalize "mama" to indicate a desire for his mother. While some 9-month-olds may start to vocalize "mama" or "dada," the absence of these specific words is not necessarily concerning at this stage. Babies develop speech at different rates, and a range of vocalizations and babbling are common at 9 months.

The mother reports that she has not yet introduced finger foods to the baby. Introducing finger foods is recommended around this age, but the absence of finger foods does not necessarily indicate a problem. The focus should be on ensuring a variety of textures and foods are introduced in the coming months to support oral and motor development.

EXPLANATION

✔Correct answer:

Identity vs. Role confusion. According to Erik Erikson's theory of psychosocial development, the stage of adolescence is characterized by the conflict of "Identity vs. Role confusion." This stage typically occurs during the teenage years, from about 12 to 18 years old. During this period, adolescents are exploring their personal identity, future ambitions, and social dynamics among peers, which aligns with the topics Nurse Harris discusses in the group. Successfully resolving this conflict leads to a strong sense of identity, while failure to do so can result in role confusion and a weak sense of self.

Erikson believed that each stage of development is marked by a specific conflict that serves as a turning point in development. The "Identity vs. Role confusion" stage is crucial for forming a strong identity and direction for the future. Adolescents experiment with different roles, beliefs, and relationships to develop a cohesive sense of self.

Think of this stage like trying on different outfits to see which one fits best. Adolescents are trying on different identities, interests, and roles to see which ones feel right for them, helping them to discover who they really are.

Nurse Harris can support adolescents in navigating this stage by providing a safe and supportive environment for exploration and discussion.

• Encourage open discussions about personal interests, values, and future goals.
• Provide resources and guidance for career exploration and educational opportunities.
• Support adolescents in building healthy relationships and social networks.
• Promote self-reflection activities to help adolescents understand their strengths and interests.
• Offer reassurance and normalization of the identity exploration process to reduce anxiety and confusion.

✘Incorrect answer options:

Relationship testing. While adolescents do test and explore relationships, this term does not accurately reflect Erikson's specific stage of psychosocial development.

Career experimentation. Career experimentation is a part of identity exploration but does not encompass the broader developmental challenge of forming a cohesive sense of identity versus experiencing role confusion.

Adolescent rebellion. Adolescent rebellion can occur during this stage as a part of identity exploration and assertion of independence, but it is not the primary conflict identified by Erikson's theory.

EXPLANATION

✔Correct answer:

12 months. The Denver Developmental Screening Test (DDST) is a standardized tool used to assess the developmental progress of children from birth to 6 years of age. According to the DDST, the median age by which most children start walking independently is approximately 12 months. It is important to note that there is a range of normal variability in developmental milestones, and some children may begin walking a few months earlier or later than this median age.

Think of learning to walk as similar to learning to ride a bicycle. Some children might pick it up a bit earlier, while others might take a bit longer, but most will learn around the same general time frame.

Nurse Reynolds should provide reassurance to Taylor that Cassie’s development is within the normal range and offer guidance on promoting motor development.

• Reassure Taylor that it is normal for some children to start walking as late as 15 months and that Cassie is still within the typical developmental range.
• Encourage activities that promote motor skills, such as supervised floor play, using push toys, and providing opportunities for Cassie to pull herself up to stand.
• Monitor Cassie’s progress and ensure regular follow-up visits to track her developmental milestones.
• Educate Taylor on signs that might indicate developmental delays and when to seek further evaluation.

✘Incorrect answer options:

10 months. While some children may start walking as early as 10 months, this is earlier than the median age and not typical for most children.

15 months. While 15 months is still within the normal range for starting to walk, it is later than the median age of 12 months. Delayed walking beyond 15 months might warrant further assessment.

14 months. This is also later than the median age, although within the normal range, but most children begin walking around 12 months.

EXPLANATION

✔Correct answer:

Presence of polycythemia. Polycythemia is a condition characterized by an increased number of red blood cells in the bloodstream. It is often associated with congenital heart disease, particularly in cases where there is chronic hypoxia. The increased red cell mass raises blood viscosity, which can lead to sluggish blood flow and an increased risk of thrombosis. These blood clots can travel to the brain, causing a cerebrovascular accident (CVA), also known as a stroke.

In congenital heart disease, especially cyanotic heart defects, the body compensates for low oxygen levels by producing more red blood cells, leading to polycythemia. This thickened blood can predispose patients to clot formation, as it flows more slowly and can easily form clots, which can then obstruct cerebral arteries and cause a stroke.

Imagine traffic on a highway where more and more cars (red blood cells) are added to the lanes. As the highway becomes congested, the likelihood of traffic jams (blood clots) increases, which can then cause accidents (strokes) when the traffic (blood flow) is suddenly blocked.

Nurses should monitor patients with congenital heart disease for signs of polycythemia and educate them about the symptoms of stroke. Regular follow-ups and hematologic evaluations are essential for early detection and management.

• Monitor hematocrit levels regularly to assess for polycythemia.
• Educate the patient and family about the signs and symptoms of a stroke, such as sudden weakness, facial drooping, and difficulty speaking.
• Encourage hydration to reduce blood viscosity.
• Collaborate with the healthcare team to manage underlying heart conditions and reduce hypoxia.
• Administer medications such as antiplatelet agents or anticoagulants as prescribed to prevent thrombus formation.

✘Incorrect answer options:

Persistently low blood pressure. Low blood pressure is generally not associated with an increased risk of CVA. While hypotension can cause inadequate cerebral perfusion, it does not typically lead to the formation of clots that cause strokes.

Presence of cardiomyopathy. Cardiomyopathy can lead to heart failure and arrhythmias, which can increase the risk of thromboembolism. However, polycythemia is more directly linked to CVA in congenital heart disease due to increased blood viscosity and clot formation.

Development of endocarditis. Endocarditis can lead to embolic strokes if vegetations (clumps of infection) dislodge and travel to the brain. However, this is less common compared to the risk posed by polycythemia in patients with congenital heart disease.

EXPLANATION

✔Correct answer:

Supine for several hours to minimize the risk of post-procedure headache. After a lumbar puncture, it is recommended to have the patient lie in a supine (flat on the back) position for several hours. This positioning helps to minimize the risk of developing a post-lumbar puncture headache, which is a common complication caused by leakage of cerebrospinal fluid (CSF) from the puncture site. Lying flat helps reduce the pressure differential and allows the puncture site to heal more effectively, thereby reducing the chances of CSF leakage.

Think of the puncture site as a small hole in a water balloon. Lying flat helps keep the hole sealed and minimizes water (CSF) leakage, which helps prevent the balloon (body) from losing too much water and causing a headache.

Nurse Bennett should ensure that Karen is positioned supine and monitor her for any signs of complications. Encouraging hydration and monitoring for headache or other symptoms is also essential.

• Keep Karen in a supine position for at least one to two hours, or as recommended by the healthcare provider, to minimize the risk of headache.
• Encourage fluid intake to help replenish any CSF lost and to maintain hydration.
• Monitor Karen for any signs of headache, nausea, or other adverse effects following the procedure.
• Provide comfort measures and pain relief if Karen experiences a headache or discomfort.
• Educate Karen and her family about the importance of following post-procedure instructions and when to seek medical attention if symptoms worsen.

✘Incorrect answer options:

In a semi-Fowler's position so she can comfortably watch TV for five hours. While this position might be comfortable for watching TV, it does not help minimize the risk of a post-lumbar puncture headache and may increase the likelihood of CSF leakage.

Prone for two hours to reduce the risk of aspiration if she vomits. The prone position is not necessary and may not be comfortable or practical for an extended period. Supine is the preferred position for minimizing post-lumbar puncture headache.

Lying on her right side to facilitate the return of CSF. This position is not recommended as it does not specifically address the prevention of a post-lumbar puncture headache. The supine position is more effective for this purpose.

EXPLANATION

✔Correct answer:

Rapid heartbeat (tachycardia), nausea, vomiting, heart palpitations, inability to sleep (insomnia), restlessness, and seizures. Bronchodilators, particularly beta-agonists like albuterol and other similar medications, are commonly used in the management of asthma. These medications can stimulate the sympathetic nervous system, leading to various side effects. Nurse Thompson should be particularly vigilant for signs such as tachycardia, nausea, vomiting, heart palpitations, insomnia, restlessness, and seizures, which can indicate adverse reactions to bronchodilators. These symptoms are associated with the overstimulation of beta receptors in the heart and central nervous system.

Bronchodilators work by relaxing the smooth muscles in the airways, which helps to open the airways and make breathing easier. However, they can also affect other parts of the body, leading to systemic side effects. Tachycardia and heart palpitations occur due to increased heart rate and contractility. Nausea and vomiting can result from the gastrointestinal effects of the medication. Insomnia and restlessness are due to CNS stimulation, and in severe cases, seizures can occur.

Think of bronchodilators like a strong cup of coffee. While they help you stay alert (open airways), too much can make you jittery, keep you awake, and cause your heart to race, just like these medications can cause restlessness, insomnia, and tachycardia.

Nurse Thompson should monitor Ms. Davis closely for these side effects and take appropriate actions if they occur.

• Monitor vital signs regularly, particularly heart rate and blood pressure.
• Assess for gastrointestinal symptoms such as nausea and vomiting.
• Observe for signs of CNS stimulation, including restlessness, insomnia, and any unusual behavior.
• Report any severe side effects, such as seizures or persistent tachycardia, to the healthcare provider immediately.
• Educate Ms. Davis about the potential side effects of bronchodilators and when to seek medical attention.

✘Incorrect answer options:

Blurred vision, rapid heartbeat (tachycardia), high blood pressure (hypertension), headache, difficulty sleeping (insomnia), and reduced urine output (oliguria). While some of these symptoms can be associated with bronchodilators, reduced urine output is not typically a side effect of these medications.

Rapid heartbeat (tachycardia), headache, shortness of breath (dyspnea), body temperature of 101 F, and wheezing. This combination includes symptoms that are more likely related to the underlying asthma condition rather than specifically indicating adverse reactions to bronchodilators.

Restlessness, difficulty sleeping (insomnia), blurred vision, high blood pressure (hypertension), chest pain, and muscle weakness. Although some of these symptoms can occur with bronchodilator use, muscle weakness is not a common side effect of these medications.

EXPLANATION

✔Correct answer:

Remove any potential hazards from the area and ensure the child is in a safe position. During a seizure, the primary concern is to ensure the safety of the patient. This involves removing any objects that could cause injury and positioning the child in a way that prevents harm. This means placing the child on their side to maintain an open airway and to allow any secretions to drain, thus reducing the risk of aspiration.

During a seizure, there is abnormal electrical activity in the brain, which can cause convulsions and loss of consciousness. Ensuring the child's environment is safe prevents injuries from uncontrolled movements. Positioning the child on their side helps to keep the airway clear and reduces the risk of choking or aspiration.

Think of the seizure as a stormy sea. The child is a small boat being tossed around. The most important thing is to make sure the boat (child) doesn't crash into rocks (hazards) and that water (secretions) doesn't flood the boat, ensuring it remains as safe as possible during the storm.

Nurse Anderson should stay with the child and ensure their environment is free from hard or sharp objects that could cause injury. She should position the child on their side, monitoring the airway and breathing, and provide reassurance to the mother, explaining what she is doing to ensure the child's safety.

• Remove objects like furniture, toys, or medical equipment that could cause injury.
• Position the child on their side to maintain an open airway and allow secretions to drain.
• Stay with the child throughout the seizure to monitor their condition and provide reassurance.
• Explain to the mother what actions are being taken and why, to help alleviate her distress.
• After the seizure, assess the child's condition and provide postictal care as needed.

✘Incorrect answer options:

Immediately call the operator to announce a seizure emergency. While calling for help is important, the immediate priority is the child's safety. Removing hazards and ensuring a safe position takes precedence. Once the child is safe, additional help can be summoned.

Place a padded tongue blade in the patient's mouth to prevent swallowing or choking on the tongue. This is outdated and dangerous advice. Placing anything in the mouth during a seizure can cause injury to the teeth or gums and increase the risk of choking. The tongue cannot be swallowed during a seizure.

Assist the mother in restraining the child to prevent potential self-injury. Restraining a child during a seizure can cause additional harm. The focus should be on ensuring a safe environment and allowing the seizure to run its course while minimizing the risk of injury.

EXPLANATION

✔Correct answer:

"Offer a variety of healthy snacks throughout the day instead of focusing solely on meals." Toddlers often have small stomachs and short attention spans, which makes it challenging for them to sit through and finish entire meals. By offering a variety of healthy snacks throughout the day, parents can ensure that their children receive adequate nutrition without the pressure of finishing large meals. This approach also helps introduce different types of food, promoting a balanced diet and making eating a more enjoyable experience for the child.

At this age, children need frequent, small meals to meet their high energy needs and nutrient requirements. Healthy snacks can include fruits, vegetables, whole grains, dairy products, and proteins, which can help cover the necessary food groups and nutrients toddlers need.

Think of a toddler’s eating habits like a car that needs frequent refueling. Instead of waiting for the tank to be empty and then filling it up completely (which can be overwhelming), it's better to add small amounts of fuel frequently to keep it running smoothly.

Nurse Thompson should educate the mother on the importance of offering balanced, nutrient-dense snacks and avoiding foods high in sugar and unhealthy fats. She can provide practical tips on meal planning and portion sizes suitable for a toddler.

• Encourage the mother to offer small portions of a variety of foods throughout the day.
• Advise against pressuring the child to eat, which can create negative associations with food.
• Suggest involving the child in food selection and preparation to make mealtime more engaging.
• Highlight the importance of regular meal and snack times to establish a routine.
• Recommend keeping a food diary to track the child's intake and identify any potential dietary gaps.

✘Incorrect answer options:

"Force your child to finish every meal to ensure they get enough nutrients." Forcing a child to eat can lead to negative associations with food, increased stress during mealtimes, and potential issues with overeating or undereating in the future. It is not a recommended practice.

"Reduce the amount of food offered to avoid overwhelming your child." While portion control is important, simply reducing the amount of food without offering variety and frequency may not meet the child's nutritional needs. It's better to provide small, balanced meals and snacks.

"Allow your child to eat only when they show signs of hunger, even if they skip meals." Toddlers might not reliably communicate hunger, and skipping meals regularly can lead to nutrient deficiencies. A structured routine with regular meal and snack times is more beneficial for their growth and development.

EXPLANATION

✔Correct answer:

Group A β-hemolytic streptococcus. Rheumatic fever is primarily caused by an infection with Group A β-hemolytic streptococcus (GABHS), also known as Streptococcus pyogenes. This bacterium is responsible for conditions such as strep throat and scarlet fever. If these infections are not adequately treated, the immune response to the bacteria can lead to rheumatic fever, an inflammatory disease that can affect the heart, joints, skin, and brain.

The exact mechanism involves an abnormal immune reaction. The body's immune system generates antibodies to fight the streptococcal infection, but these antibodies can mistakenly attack the body's own tissues, particularly the heart valves, joints, and central nervous system. This molecular mimicry leads to the inflammation and damage characteristic of rheumatic fever.

Think of Group A β-hemolytic streptococcus like a band of robbers (the bacteria) breaking into a house (the body). The security system (immune system) responds by identifying and attacking the robbers. However, if the system is not precise, it may also damage the furniture (body's own tissues) in the process, causing unintended harm.

During health education sessions, nurses should emphasize the importance of early detection and treatment of streptococcal infections to prevent rheumatic fever. This includes seeking medical attention for sore throats and completing the full course of prescribed antibiotics.

• Educate parents on the signs and symptoms of streptococcal infections and the necessity of timely medical intervention.
• Emphasize the importance of adhering to antibiotic regimens to eradicate the infection completely.
• Inform about the potential complications of untreated streptococcal infections, including rheumatic fever.
• Encourage good hygiene practices to prevent the spread of streptococcal bacteria.
• Provide resources for parents to understand more about rheumatic fever and its long-term management.

✘Incorrect answer options:

Haemophilus influenzae. This bacterium can cause respiratory tract infections and other illnesses but is not associated with the development of rheumatic fever.

Streptococcal pneumonia. This refers to Streptococcus pneumoniae, which causes pneumococcal infections like pneumonia, meningitis, and otitis media. It is not the causative agent of rheumatic fever.

Staphylococcus aureus. This bacterium can cause various infections, including skin infections, pneumonia, and sepsis. However, it is not linked to rheumatic fever.

EXPLANATION

✔Correct answer:

Ceasing all monitoring of the child immediately after the chemotherapy infusion is complete. It is inappropriate for Nurse Thompson to cease all monitoring of the child immediately after the chemotherapy infusion is complete. Chemotherapy drugs can cause delayed adverse reactions that may not present immediately during or right after the infusion. Continuous monitoring post-infusion is crucial to detect any late-onset side effects, including anaphylactic reactions, changes in vital signs, and other complications such as infusion-related reactions or delayed hypersensitivity.

Chemotherapy agents can cause a range of side effects that may present immediately, shortly after, or even days after administration. Immediate side effects might include nausea, vomiting, and allergic reactions, whereas delayed effects might encompass bone marrow suppression, nephrotoxicity, hepatotoxicity, and mucositis. Ensuring ongoing monitoring helps in early detection and management of these potential adverse effects.

Think of chemotherapy administration like a marathon race. Just because the race (infusion) has finished doesn't mean the runner (patient) stops experiencing effects immediately. The runner needs cool-down time and monitoring to ensure they recover properly and to catch any issues that arise post-race.

Nurses should maintain vigilance even after the chemotherapy infusion is completed, continuing to monitor the patient's vital signs, watching for signs of delayed adverse reactions, and being prepared to intervene promptly if complications arise.

• Continue monitoring the patient's vital signs for at least 30 minutes to an hour post-infusion or as per institutional protocols.
• Educate the patient and family about potential delayed side effects and when to seek medical help.
• Ensure the availability of emergency medications and equipment to manage any sudden adverse reactions.
• Document any adverse reactions and communicate with the healthcare team for ongoing patient management.

✘Incorrect answer options:

Remaining vigilant for 10 minutes following the administration to observe any indications of anaphylaxis. This is an appropriate action. Immediate vigilance post-administration is critical to detect any acute hypersensitivity reactions, including anaphylaxis, which can be life-threatening and require prompt intervention.

Consistently observing the child for a broad spectrum of potential adverse reactions associated with the medication. This is also an appropriate action. Continuous observation helps in early detection and management of various adverse reactions, ensuring patient safety.

Diligently inspecting for any evidence of infusion infiltration and irritation at the administration site. This is another appropriate action. Monitoring the infusion site for signs of infiltration or irritation is essential to prevent and manage local tissue damage and ensure proper delivery of the medication.

EXPLANATION

✔Correct answer:

Proceeding from the least intrusive to the most intrusive procedures. The most effective method for conducting a physical examination on a 2-year-old toddler is to proceed from the least intrusive to the most intrusive procedures. Toddlers can be easily frightened and uncooperative during a physical examination. By starting with less intrusive procedures, such as inspecting the child's general appearance, vital signs, and extremities, the nurse can build trust and reduce the child's anxiety. More intrusive procedures, such as examining the ears, mouth, and abdomen, should be left for last when the child might be more accustomed to the nurse and the examination process.

Understanding child development is crucial in pediatric nursing. Toddlers are in the developmental stage where they seek autonomy and can be fearful of new experiences and strangers. By approaching the examination in a non-threatening manner, the nurse can facilitate cooperation and obtain more accurate assessment data.

Imagine taking a toddler to a new playground. If you first introduce them to the gentler and less intimidating areas, they are more likely to feel comfortable and explore more challenging areas later. Similarly, starting with less intrusive parts of the examination helps the child feel safer and more cooperative.

When performing a physical examination on a toddler, nurses should be mindful of the child's comfort and fears. Techniques such as using a calm voice, explaining procedures in simple terms, and allowing the child to handle safe medical instruments can help alleviate anxiety.

• Start with less invasive procedures such as observation and palpation of the extremities.
• Save the most invasive procedures, like examining the throat and ears, for last.
• Allow the child to sit on a parent's lap if it makes them feel more secure.
• Use distraction techniques such as toys or talking to the child about their favorite things.
• Praise the child for their cooperation throughout the examination.

✘Incorrect answer options:

Starting from the abdomen and moving to the toes, then finishing at the head. This approach is not ideal because the abdomen examination can be intrusive and distressing for a toddler, potentially causing them to become uncooperative early in the process.

Beginning at the head and examining down to the toe. While systematic, starting at the head can be intrusive, especially when examining the ears and mouth, which can be distressing for a toddler and make the rest of the examination more challenging.

Examining from the distal parts of the body towards the proximal parts. This method does not account for the need to build trust and minimize anxiety. The focus should be on the level of intrusiveness rather than the anatomical direction.

EXPLANATION

✔Correct answer:

Checking the skin for any breaks or pressure sores. While it is important to monitor for skin integrity around the cast, especially to prevent pressure sores or breaks in the skin, this is not the most critical assessment immediately following the casting of a fracture. The primary concerns initially are ensuring adequate blood flow and nerve function distal to the injury, which involves observing the movement of the fingers, measuring the radial and ulnar pulses, and testing for capillary refill. These assessments are crucial for detecting signs of compartment syndrome or other circulatory impairments that require prompt intervention.

After a fracture and casting, there is a risk of complications such as compartment syndrome, where increased pressure within a confined space (e.g., within the cast) can compromise circulation and nerve function. Early detection through neurovascular assessments is essential to prevent permanent damage.

Imagine a garden hose (the arm) with a kink (the fracture). The most important thing to check is if water (blood and nerve signals) can still flow past the kink (distal to the injury). Checking for leaks (skin breaks or sores) is important but not as immediately critical as ensuring the flow continues.

Nurse Thompson should prioritize neurovascular checks and ensure that the cast is not too tight, followed by monitoring skin integrity.

• Monitor the patient’s ability to move fingers distal to the cast to ensure there is no nerve impairment.
• Regularly check the radial and ulnar pulses to ensure adequate blood flow to the hand and fingers.
• Test capillary refill by pressing on the nail beds and observing the time it takes for color to return, which should be less than 2 seconds.
• While checking for skin breaks or pressure sores is still important, it is secondary to ensuring proper circulation and nerve function in the immediate post-casting period.
• Educate the patient and family on signs of complications, such as increased pain, swelling, or numbness, and the importance of reporting these symptoms promptly.

✘Incorrect answer options:

Observing the movement of the fingers. This is crucial to ensure there is no nerve impairment or muscle damage distal to the cast.

Measuring the radial and ulnar pulses. This is essential to assess blood flow and ensure there is no vascular compromise.

Testing for capillary refill. This is important to assess peripheral circulation and ensure there is no compromise in blood flow to the fingers.