the nurse is teaching the mother of a 5 year old boy with a myelomeningocele who has developed a sensitivity to latex which response from his mother i
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Pediatric HESI Practice Questions

1. The mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex is being taught by the nurse. Which response from his mother indicates a need for further teaching?

Correct answer: C

Rationale: Choice C indicates a need for further teaching because not all products are clearly labeled as latex-free. It is essential for the mother to understand that she should not solely rely on product labels to determine latex content. She should be encouraged to verify with manufacturers and consult healthcare providers for accurate information. Choices A, B, and D are correct responses. Wearing a medical alert identification, informing caregivers, and ensuring the boy avoids all contact with latex are crucial steps in managing his sensitivity to latex and preventing potential allergic reactions.

2. A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken?

Correct answer: C

Rationale: In this scenario, the correct answer is C. Any vital signs outside the expected range in an infant should be documented and reported, as they may indicate a developing condition that requires prompt attention. Choice A is incorrect because slow respirations in infants should not be dismissed without assessment and documentation. Choice B is incorrect because a drop in respiratory rate in this case was significant and should have been documented. Choice D is incorrect because even though infants have underdeveloped respiratory tracts, any abnormal respiratory rate should be taken seriously and documented for monitoring and intervention if necessary.

3. Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?

Correct answer: C

Rationale: The most appropriate nursing diagnosis for a child with acute glomerulonephritis is fluid volume excess related to decreased plasma filtration. Acute glomerulonephritis is characterized by inflammation of the glomeruli in the kidneys, leading to decreased plasma filtration and retention of fluid. This results in fluid volume excess rather than fluid deficit (choice B) or fluid accumulation in tissues and third spaces (choice D). The diagnosis of 'risk for injury related to malignant process and treatment' (choice A) is not directly related to the pathophysiology of acute glomerulonephritis.

4. When teaching an adolescent with type 1 diabetes about dietary management, what should the nurse include?

Correct answer: C

Rationale: The correct answer is C: A ready source of glucose should be available. When managing type 1 diabetes, it is crucial to have a quick source of glucose readily available in case of hypoglycemia. This ensures that the adolescent can quickly raise their blood sugar levels to prevent complications. Choices A, B, and D are incorrect as they do not address the immediate need for glucose in managing hypoglycemia. While it is important for meals to be consumed regularly and in a controlled manner, specifying that they should be eaten at home or foods weighed using a gram scale is not as critical as ensuring a quick source of glucose in emergency situations.

5. The parents of a 1-month-old girl with Down syndrome are being taught by the nurse on how to maintain the child's good health. Which instruction would the nurse be least likely to include?

Correct answer: B

Rationale: The correct answer is B. While special dietary needs may be important, they are not typically a primary concern for a 1-month-old with Down syndrome compared to monitoring for congenital issues. Getting cervical radiographs, an echocardiogram, and monitoring for respiratory infections are more crucial in the early care of a child with Down syndrome. Cervical radiographs help in assessing for atlantoaxial instability, an echocardiogram is important for detecting congenital heart defects common in Down syndrome, and monitoring for respiratory infections is vital due to the increased risk in these children.

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