a teen with asthma asks the nurse why it is hard to breathe during an asthma attack the nurse explains that exposure to a trigger results in which of

ATI RN

RN Nursing Care of Children 2019 With NGN

1. A teen with asthma asks the nurse why it is hard to breathe during an asthma attack. The nurse explains that exposure to a “trigger” results in which of these manifestations?

A. Bronchodilation, muscle relaxation, and decreased mucus production
B. Air trapping and hypo-inflation of the alveoli
C. Air trapping and decreased blood flow to the upper airway
D. Bronchoconstriction, airway inflammation, and excess mucus production

Correct answer: D

Rationale: The correct answer is D. Asthma triggers cause bronchoconstriction, airway inflammation, and increased mucus production, leading to difficulty breathing. This combination of manifestations results in narrowing of the airways, making it hard for the individual to breathe effectively. Choices A, B, and C are incorrect because during an asthma attack, bronchodilation, muscle relaxation, and decreased mucus production do not occur. Instead, the airways constrict, become inflamed, and produce excess mucus, contributing to the breathing difficulties experienced by individuals with asthma.

2. Which action should the nurse implement when taking an axillary temperature?

A. Take the temperature through one layer of clothing
B. Add a degree to the result when recording
C. Place the tip of the thermometer under the arm in the center of the axilla
D. Hold the child's arm away from the body while taking the temperature

Correct answer: C

Rationale: The correct technique involves placing the thermometer tip in the center of the axilla to ensure an accurate reading, with the arm held close to the body.

3. Why is knowledge of developmental theories useful for the nurse?

A. Allows the nurse to know exactly what to do when caring for pediatric patients
B. Is predictable and aids in controlling the child’s development
C. Is a set of facts that each child follows in a prescribed method
D. Provides a framework to guide the nurse in caring for the patient

Correct answer: D

Rationale: The correct answer is D. Understanding developmental theories helps nurses anticipate and plan appropriate care based on the child’s developmental stage. Choice A is incorrect because developmental theories provide a framework but do not dictate exact actions. Choice B is incorrect as developmental processes are not entirely predictable and are not meant to control a child’s development. Choice C is incorrect as developmental theories are not a strict set of facts that all children follow in a prescribed manner, but rather guidelines for understanding and supporting a child's growth and development.

4. An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Postoperative nursing care would include what?

A. Monitor closely for signs of infection.
B. Place the child with the operative side of the head up.
C. Avoid pumping the shunt reservoir to maintain patency.
D. Avoid maintaining a Trendelenburg position to decrease pressure on the shunt.

Correct answer: A

Rationale: Postoperative nursing care for an infant with hydrocephalus who underwent ventriculoperitoneal shunt placement includes monitoring closely for signs of infection, as infection is the greatest hazard in the postoperative period. Signs of cerebrospinal fluid infection to watch for include elevated temperature, poor feeding, vomiting, decreased responsiveness, and seizure activity. The child should be placed with the operative side of the head up to reduce pressure on the valve. The shunt reservoir should not be pumped to maintain patency, as this can disrupt its function. Maintaining a Trendelenburg position to decrease pressure on the shunt is contraindicated as it can lead to increased intracranial pressure and compromise the shunt's effectiveness.

5. What interventions should be implemented to maintain the skin integrity of a preterm infant born at 30 weeks?

A. Avoid cleaning the skin
B. Bathe the infant with sterile water
C. Cleanse the skin with a gentle alkaline-based soap and water
D. Thoroughly rinse the skin with plain water after bathing

Correct answer: B

Rationale: The correct intervention to maintain the skin integrity of a preterm infant born at 30 weeks is to bathe the infant with sterile water. Bathing with sterile water or a neutral pH solution is recommended to protect the delicate skin of preterm infants, which is more permeable and prone to damage. Choices A, C, and D are incorrect as avoiding cleaning the skin may lead to hygiene issues, cleansing with alkaline-based soap can be harsh on the delicate skin, and thoroughly rinsing with plain water after bathing may not be as gentle and protective for preterm infants.