what is the most appropriate nursing action for a child with epistaxis
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Nursing Elites

ATI RN

ATI Nursing Care of Children 2019 B

1. What is the most appropriate action for a child with epistaxis?

Correct answer: B

Rationale: The most appropriate action for a child with epistaxis is to pinch the nose and lean forward. This technique helps stop the bleeding and prevent aspiration of blood. By applying pressure to the bleeding vessels and allowing the blood to drain out of the nostrils instead of being swallowed, the risk of nausea and airway obstruction is reduced. Having the child lie flat (Choice A) may lead to blood flowing down the throat, causing potential choking. Applying a warm compress (Choice C) is not typically recommended for epistaxis as cold compresses are more effective. Encouraging deep breathing (Choice D) is not directly related to managing epistaxis.

2. Which laboratory test would be most important for the nurse to assess when caring for a toddler suspected of having cystic fibrosis?

Correct answer: C

Rationale: The sweat chloride test is the primary diagnostic test for cystic fibrosis. Cystic fibrosis is characterized by abnormal transport of chloride and sodium across epithelial cell membranes, leading to increased chloride in sweat. This test is crucial for diagnosing cystic fibrosis in suspected cases. Liver enzymes (Choice A), serum calcium (Choice B), and urine creatinine (Choice D) are not specific tests for cystic fibrosis and would not provide the necessary information for diagnosis in this case.

3. The nurse is preparing to admit a 6-month-old child with gastroesophageal reflux disease. What clinical manifestations should the nurse expect to observe?

Correct answer: D

Rationale: The correct answer is D, as gastroesophageal reflux disease (GERD) in infants typically presents with symptoms such as spitting up, failure to thrive, excessive crying, and respiratory problems due to aspiration. Bilious vomiting is not a common symptom of GERD in infants and may indicate a different or more severe condition, such as intestinal obstruction or other gastrointestinal issues. Therefore, choices A, B, and C are all expected clinical manifestations of GERD in a 6-month-old child, making option D the correct answer.

4. The nurse is caring for a child with Meckel diverticulum. What type of stool does the nurse expect to observe?

Correct answer: C

Rationale: Corrected Rationale: Currant jelly-like stools, which contain blood and mucus, are characteristic of Meckel diverticulum. This symptom occurs due to the bleeding from the ectopic gastric mucosa present in the diverticulum. Steatorrhea (choice A) is not typically associated with Meckel diverticulum. Clay-colored stools (choice B) are seen in conditions affecting the biliary system. Loose stools with undigested food (choice D) may indicate malabsorption issues, but it is not specifically linked to Meckel diverticulum.

5. The nurse is preparing to admit a 7-year-old child with Crohn disease. What clinical manifestations should the nurse expect to observe?

Correct answer: C

Rationale: The correct answer is C because Crohn's disease commonly presents with pain, severe weight loss, and moderate to severe diarrhea in affected individuals. Therefore, all the manifestations listed are typically observed in patients with Crohn's disease. Choice A alone is not sufficient as weight loss and diarrhea are also prominent symptoms. Choice B is incorrect as it only mentions weight loss, omitting other common manifestations. Choice D is also incorrect as it does not cover the full range of expected clinical signs in Crohn's disease.

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