what is an essential nursing action when caring for a young child with severe diarrhea
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Pediatric HESI Test Bank

1. What is an essential nursing action when caring for a young child with severe diarrhea?

Correct answer: D

Rationale: Promoting perianal skin integrity is crucial when caring for a young child with severe diarrhea as it helps prevent skin breakdown from the irritation caused by frequent stooling. Maintaining the IV (Choice A) may be necessary but is not directly related to managing perianal skin integrity. Taking daily weights (Choice B) is important for monitoring fluid status but not the priority when addressing perianal skin integrity. While replacing lost calories (Choice C) is essential, promoting perianal skin integrity takes precedence in preventing complications associated with skin breakdown.

2. A healthcare provider is preparing to administer an oral medication to a 4-year-old child. What is the best approach to gain the child's cooperation?

Correct answer: B

Rationale: Allowing the child to play with a favorite toy while taking the medication is the best approach to gain the child's cooperation. This strategy can help distract and calm the child, making the medication administration process smoother. Explaining the medication's importance (Choice A) may not be as effective in gaining immediate cooperation from a young child who may not fully understand. Offering a reward after the medication is taken (Choice C) may create a dependency on rewards for cooperation. Giving the medication mixed with food (Choice D) may not always be appropriate or recommended, especially if the child needs to take the medication on an empty stomach.

3. At 7 AM, a nurse receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

Correct answer: D

Rationale: Rapid acting insulin will help lower the elevated blood glucose level quickly.

4. The healthcare provider is assessing an infant and notes that the infant's urine has a mousy or musty odor. What would the healthcare provider suspect?

Correct answer: C

Rationale: Phenylketonuria (PKU) is suggested by a mousy or musty odor of the urine, caused by the inability to metabolize phenylalanine. Maple syrup urine disease (Choice A) is characterized by a sweet-smelling urine. Tyrosinemia (Choice B) presents with cabbage-like odor in the urine. Trimethylaminuria (Choice D) results in a fishy odor in the urine, breath, and sweat.

5. What should the nurse suggest to a parent asking for advice on managing their child's earache and fever?

Correct answer: A

Rationale: The correct answer is to suggest applying a warm compress to the affected ear. This can help alleviate pain and discomfort associated with the earache. Giving a cold drink (Choice B) may not address the underlying issue and is not a recommended treatment for earaches. Administering acetaminophen (Choice C) can help reduce fever but may not directly target the earache. Taking the child to the emergency department (Choice D) is usually not necessary for a common earache unless there are severe symptoms or complications present.

Similar Questions

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