Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 10-year-old with sickle cell disease reports frequent joint pain. Which nursing intervention is most appropriate?
A. Provide scheduled analgesics and encourage nonpharmacologic strategies
Provide scheduled analgesics and encourage nonpharmacologic strategies is correct. Children with sickle cell disease often experience recurrent pain episodes due to vaso-occlusion. Managing pain effectively involves scheduled analgesics, such as acetaminophen or opioids for severe pain, to maintain consistent relief, along with nonpharmacologic strategies like heat application, relaxation techniques, and distraction. This approach prevents pain escalation and improves quality of life.
B. Administer medication only when the child requests it
Administer medication only when the child requests it is incorrect because children with chronic pain may underreport pain or wait until it is severe. Scheduled dosing ensures consistent pain control and prevents unnecessary suffering.
C. Limit physical activity to prevent pain episodes
Limit physical activity to prevent pain episodes is incorrect because while extreme exertion can trigger a pain crisis, normal activity should be encouraged as tolerated to maintain mobility, muscle strength, and overall health. Over-restriction can negatively affect development and psychosocial well-being.
D. Encourage the child to ignore the pain
Encourage the child to ignore the pain is incorrect because ignoring pain can lead to delayed treatment, increased suffering, and potential complications such as prolonged vaso-occlusive crises. Pain should be acknowledged and managed appropriately.
This question is an excerpt from Nurse Dive's nursing test bank - Ati dmmsn 650 OB/Pediatrics Proctored Exams. Take the full exam now
Full Explanation
A. Provide scheduled analgesics and encourage nonpharmacologic strategies is correct. Children with sickle cell disease often experience recurrent pain episodes due to vaso-occlusion. Managing pain effectively involves scheduled analgesics, such as acetaminophen or opioids for severe pain, to maintain consistent relief, along with nonpharmacologic strategies like heat application, relaxation techniques, and distraction. This approach prevents pain escalation and improves quality of life.
B. Administer medication only when the child requests it is incorrect because children with chronic pain may underreport pain or wait until it is severe. Scheduled dosing ensures consistent pain control and prevents unnecessary suffering.
C. Limit physical activity to prevent pain episodes is incorrect because while extreme exertion can trigger a pain crisis, normal activity should be encouraged as tolerated to maintain mobility, muscle strength, and overall health. Over-restriction can negatively affect development and psychosocial well-being.
D. Encourage the child to ignore the pain is incorrect because ignoring pain can lead to delayed treatment, increased suffering, and potential complications such as prolonged vaso-occlusive crises. Pain should be acknowledged and managed appropriately.
Similar Questions
A 22-year-old pregnant woman reports craving and eating non-food items such as ice, clay, and dirt. Which of the following statements by the nurse is correct?
A. "You should be encouraged to eat more of these items to satisfy cravings.
"You should be encouraged to eat more of these items to satisfy cravings." is incorrect because consuming non-food items like ice, clay, or dirt can be harmful. These substances may contain toxins or pathogens and can interfere with nutrient absorption. Encouraging this behavior would be unsafe.
B. "This is a normal behavior during pregnancy and does not require intervention."
"This is a normal behavior during pregnancy and does not require intervention." is incorrect because while cravings are common in pregnancy, PICA is an abnormal eating behavior involving non-food items and requires assessment and intervention due to potential health risks.
C. This behavior, called PICA, may lead to nutritional deficiencies and should be assessed."
"This behavior, called PICA, may lead to nutritional deficiencies and should be assessed." is correct. PICA is the recurrent consumption of non-nutritive substances and is often associated with iron deficiency anemia and other nutritional deficiencies. The nurse should assess for nutritional status, laboratory abnormalities, and educate the client on potential risks to both mother and fetus.
D. "PICA only occurs in the first trimester and will resolve on its own."
"PICA only occurs in the first trimester and will resolve on its own." is incorrect because PICA can occur at any time during pregnancy and may persist throughout gestation if untreated. It does not resolve spontaneously in all cases.
Full Explanation
A. "You should be encouraged to eat more of these items to satisfy cravings." is incorrect because consuming non-food items like ice, clay, or dirt can be harmful. These substances may contain toxins or pathogens and can interfere with nutrient absorption. Encouraging this behavior would be unsafe.
B. "This is a normal behavior during pregnancy and does not require intervention." is incorrect because while cravings are common in pregnancy, PICA is an abnormal eating behavior involving non-food items and requires assessment and intervention due to potential health risks.
C. "This behavior, called PICA, may lead to nutritional deficiencies and should be assessed." is correct. PICA is the recurrent consumption of non-nutritive substances and is often associated with iron deficiency anemia and other nutritional deficiencies. The nurse should assess for nutritional status, laboratory abnormalities, and educate the client on potential risks to both mother and fetus.
D. "PICA only occurs in the first trimester and will resolve on its own." is incorrect because PICA can occur at any time during pregnancy and may persist throughout gestation if untreated. It does not resolve spontaneously in all cases.
The nurse is assessing a newborn who is 12 hours old. Which symptoms would indicate the newborn is experiencing respiratory distress? (Select all that apply)
A. inspiratory stridor
Inspiratory stridor is correct. Stridor is a high-pitched, noisy sound during inspiration caused by partial obstruction of the upper airway, such as laryngeal edema or congenital anomalies. In a newborn, stridor indicates that the infant is struggling to get enough air into the lungs, and immediate assessment is needed to prevent hypoxia.
B. increased appetite
Increased appetite is incorrect. Feeding difficulties, not increased appetite, are more likely in a newborn experiencing respiratory distress. Labored breathing can make sucking and swallowing difficult, which may lead to poor intake or fatigue during feeding.
C. retractions
Retractions are correct. Retractions occur when the intercostal muscles, subcostal areas, or suprasternal notch pull inward with inspiration. This reflects increased respiratory effort because the newborn is working harder to expand the lungs against resistance. Retractions are a classic and easily observable sign of respiratory distress.
D. nasal flaring
Nasal flaring is correct. Flaring of the nostrils occurs as the infant attempts to increase airflow into the lungs. This is a compensatory mechanism to reduce airway resistance and improve oxygen intake. Nasal flaring is particularly noticeable in newborns because their nasal passages are narrow and easily obstructed.
E. grunting
Grunting is correct. Grunting is an expiratory sound made when the newborn partially closes the glottis while exhaling. This helps maintain alveolar pressure and improve gas exchange, which is a compensatory response to lung immaturity or alveolar collapse. Persistent grunting is a red flag for significant respiratory compromise.
Full Explanation
A. Inspiratory stridor is correct. Stridor is a high-pitched, noisy sound during inspiration caused by partial obstruction of the upper airway, such as laryngeal edema or congenital anomalies. In a newborn, stridor indicates that the infant is struggling to get enough air into the lungs, and immediate assessment is needed to prevent hypoxia.
B. Increased appetite is incorrect. Feeding difficulties, not increased appetite, are more likely in a newborn experiencing respiratory distress. Labored breathing can make sucking and swallowing difficult, which may lead to poor intake or fatigue during feeding.
C. Retractions are correct. Retractions occur when the intercostal muscles, subcostal areas, or suprasternal notch pull inward with inspiration. This reflects increased respiratory effort because the newborn is working harder to expand the lungs against resistance. Retractions are a classic and easily observable sign of respiratory distress.
D. Nasal flaring is correct. Flaring of the nostrils occurs as the infant attempts to increase airflow into the lungs. This is a compensatory mechanism to reduce airway resistance and improve oxygen intake. Nasal flaring is particularly noticeable in newborns because their nasal passages are narrow and easily obstructed.
E. Grunting is correct. Grunting is an expiratory sound made when the newborn partially closes the glottis while exhaling. This helps maintain alveolar pressure and improve gas exchange, which is a compensatory response to lung immaturity or alveolar collapse. Persistent grunting is a red flag for significant respiratory compromise.
A 7-year-old child is brought to the clinic due to fatigue, slowed growth, and constipation. On examination, the child has dry skin, a puffy face, and a hoarse voice. Which of the following conditions should the nurse suspect?
A. Hypothyroidism
Hypothyroidism is correct. The child’s fatigue, slowed growth, and constipation, along with physical findings such as dry skin, puffy face, and hoarse voice, are classic signs of hypothyroidism, a condition caused by insufficient thyroid hormone production. In children, untreated hypothyroidism can lead to growth retardation, developmental delays, and delayed puberty.
B. Cushing's Syndrome
Cushing's Syndrome is incorrect because it is characterized by weight gain, truncal obesity, moon face, buffalo hump, and skin changes like striae, often with hypertension and hyperglycemia. Fatigue and constipation are less prominent, and slowed growth is not typically associated with early Cushing's.
C. Hyperthyroidism
Hyperthyroidism is incorrect because it usually presents with weight loss, increased appetite, tachycardia, heat intolerance, hyperactivity, and rapid growth, which are opposite to the findings in this child.
D. Type 1 Diabetes Mellitus
Type 1 Diabetes Mellitus is incorrect because it is usually presents with polyuria, polydipsia, polyphagia, and weight loss. Constipation, hoarse voice, and dry skin are not characteristic of diabetes.
Full Explanation
A. Hypothyroidism is correct. The child’s fatigue, slowed growth, and constipation, along with physical findings such as dry skin, puffy face, and hoarse voice, are classic signs of hypothyroidism, a condition caused by insufficient thyroid hormone production. In children, untreated hypothyroidism can lead to growth retardation, developmental delays, and delayed puberty.
B. Cushing's Syndrome is incorrect because it is characterized by weight gain, truncal obesity, moon face, buffalo hump, and skin changes like striae, often with hypertension and hyperglycemia. Fatigue and constipation are less prominent, and slowed growth is not typically associated with early Cushing's.
C. Hyperthyroidism is incorrect because it usually presents with weight loss, increased appetite, tachycardia, heat intolerance, hyperactivity, and rapid growth, which are opposite to the findings in this child.
D. Type 1 Diabetes Mellitus is incorrect because it is usually presents with polyuria, polydipsia, polyphagia, and weight loss. Constipation, hoarse voice, and dry skin are not characteristic of diabetes.