the nurse is admitting a 9 year old child with hemolytic uremic syndrome what clinical manifestations should the nurse expect to observe select all th

ATI RN

RN Nursing Care of Children 2019 With NGN

1. The nurse is admitting a 9-year-old child with hemolytic uremic syndrome. What clinical manifestations should the nurse expect to observe? (Select all that apply.)

A. All are correct
B. Anorexia
C. Hypertension
D. Purpura

Correct answer: A

Rationale: Hemolytic uremic syndrome (HUS) typically presents with hematuria, anorexia, hypertension, and purpura due to the hemolytic anemia, thrombocytopenia, and renal failure that characterize this condition.

2. In assessing sexual maturity levels, which tool would you expect to use?

A. Denver II Developmental Screening
B. Tanner staging
C. Antibody testing
D. Nursing process

Correct answer: B

Rationale: The correct answer is B: Tanner staging. Tanner staging is a tool specifically used to assess sexual maturity in adolescents based on the development of secondary sexual characteristics. The Tanner scale ranges from stage 1 (prepubertal) to stage 5 (adult maturity). This tool helps healthcare providers evaluate the physical development and sexual maturation of individuals. Choice A, the Denver II Developmental Screening, is used to assess developmental milestones in children. Choice C, antibody testing, is a diagnostic tool used to detect the presence of specific antibodies in the blood. Choice D, the nursing process, is a systematic method that nurses use to deliver patient-centered care, involving assessment, diagnosis, planning, implementation, and evaluation.

3. Which situation denotes a nontherapeutic nurse-patient-family relationship?

A. The nurse is planning to read a favorite fairy tale to a patient
B. During shift report, the nurse is criticizing parents for not visiting their child
C. The nurse is discussing with a fellow nurse the emotional draw to a certain patient
D. The nurse is working with a family to find ways to decrease the family’s dependence on health care providers

Correct answer: B

Rationale: Criticizing parents or making negative comments about their involvement is nontherapeutic and can damage the nurse-patient-family relationship.

4. Nursing care of children focuses on improving quality by:

A. Improving sanitation
B. Focusing on curing childhood illnesses
C. Addressing problems caused by communicable disease
D. Providing a holistic environment for optimal growth and development

Correct answer: D

Rationale: The correct answer is D because nursing care for children should encompass a holistic approach that considers not only physical health but also emotional, social, and developmental aspects. Providing a holistic environment promotes optimal growth and development by addressing all these dimensions. Choices A, B, and C are incorrect because while sanitation, curing illnesses, and addressing communicable diseases are important aspects of child healthcare, they do not encompass the comprehensive care provided by a holistic approach.

5. Where in the health history does a record of immunizations belong?

A. History
B. Present illness
C. Review of systems
D. Physical assessment

Correct answer: A

Rationale: Immunizations are part of the patient’s health history and are recorded under the history section to ensure the child is up-to-date with vaccinations.