Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A 6-month-old infant diagnosed with gastroesophageal reflux disease (GERD) presents with poor weight gain, frequent regurgitation, and occasional respiratory distress. The nurse must prioritize interventions to manage GERD effectively. Which nursing action is most appropriate to include in the care plan?
A. Instruct parents to feed the infant large volumes less frequently to reduce reflux episodes.
Instruct parents to feed the infant large volumes less frequently is incorrect because large feedings increase gastric distention and can worsen reflux. Small, frequent feedings are preferred.
B. Advise parents to allow the infant to sleep on their stomach to reduce reflux symptoms during sleep.
Advise parents to allow the infant to sleep on their stomach is incorrect because placing infants on their stomach increases the risk of sudden infant death syndrome (SIDS) and is not recommended. Infants should be placed on their back for sleep.
C. Recommend thickening all infant feedings with cereals to improve satiety and reduce vomiting
Recommend thickening all infant feedings with cereals is partially correct for some infants, but thickening should be guided by a healthcare provider, as it is not appropriate for all infants and can pose risks if done incorrectly.
D. Educate parents to position the infant at a 30-degree angle for 30 minutes after feeding and avoid propping bottles during feedings.
Educate parents to position the infant at a 30-degree angle for 30 minutes after feeding and avoid propping bottles during feedings is correct because upright positioning after feedings uses gravity to reduce reflux and prevents aspiration. Avoiding bottle propping reduces the risk of choking, overfeeding, and increased reflux episodes.
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. Instruct parents to feed the infant large volumes less frequently is incorrect because large feedings increase gastric distention and can worsen reflux. Small, frequent feedings are preferred.
B. Advise parents to allow the infant to sleep on their stomach is incorrect because placing infants on their stomach increases the risk of sudden infant death syndrome (SIDS) and is not recommended. Infants should be placed on their back for sleep.
C. Recommend thickening all infant feedings with cereals is partially correct for some infants, but thickening should be guided by a healthcare provider, as it is not appropriate for all infants and can pose risks if done incorrectly.
D. Educate parents to position the infant at a 30-degree angle for 30 minutes after feeding and avoid propping bottles during feedings is correct because upright positioning after feedings uses gravity to reduce reflux and prevents aspiration. Avoiding bottle propping reduces the risk of choking, overfeeding, and increased reflux episodes.
Similar Questions
What is the characteristic of the immune-mediated type 1 diabetes mellitus?
A. Oral agents are often effective for treatment.
Oral agents are often effective for treatment is incorrect because type 1 diabetes is characterized by autoimmune destruction of pancreatic beta cells, leading to absolute insulin deficiency. Insulin therapy, not oral hypoglycemic agents, is required.
B. Age at onset is usually younger than 18 years.
Age at onset is usually younger than 18 years is correct because immune-mediated type 1 diabetes typically develops in children and adolescents, although it can occur at any age. This is the classic age group for presentation of type 1 diabetes.
C. Onset is gradual.
Onset is gradual is incorrect because type 1 diabetes usually has a rapid onset of symptoms, such as polyuria, polydipsia, weight loss, and fatigue, over weeks to months.
D. Ketoacidosis is infrequent.
Ketoacidosis is infrequent is incorrect because diabetic ketoacidosis (DKA) is a common presenting feature in children with type 1 diabetes, especially at initial diagnosis, due to absolute insulin deficiency.
Full Explanation
A. Oral agents are often effective for treatment is incorrect because type 1 diabetes is characterized by autoimmune destruction of pancreatic beta cells, leading to absolute insulin deficiency. Insulin therapy, not oral hypoglycemic agents, is required.
B. Age at onset is usually younger than 18 years is correct because immune-mediated type 1 diabetes typically develops in children and adolescents, although it can occur at any age. This is the classic age group for presentation of type 1 diabetes.
C. Onset is gradual is incorrect because type 1 diabetes usually has a rapid onset of symptoms, such as polyuria, polydipsia, weight loss, and fatigue, over weeks to months.
D. Ketoacidosis is infrequent is incorrect because diabetic ketoacidosis (DKA) is a common presenting feature in children with type 1 diabetes, especially at initial diagnosis, due to absolute insulin deficiency.
A 3-month-old neonate is admitted with suspected hydrocephalus. Upon assessment, which clinical manifestation should the nurse prioritize as indicative of increased intracranial pressure?
A. Closed fontanel and high-pitched cry
Closed fontanel and high-pitched cry is incorrect because a closed fontanel is normal at this age only if ossification is occurring, and a high-pitched cry may indicate pain or neurologic irritation but is not the most specific sign of increased ICP.
B. Bulging fontanel and dilated scalp veins
Bulging fontanel and dilated scalp veins is correct because increased intracranial pressure (ICP) in infants often presents with a bulging, tense fontanel due to accumulation of cerebrospinal fluid, and prominent scalp veins result from increased venous pressure. These are hallmark early signs of hydrocephalus and warrant prompt attention.
C. Constant low-pitched cry and restlessness
Constant low-pitched cry and restlessness is incorrect because while irritability and restlessness may accompany increased ICP, a low-pitched cry is not a classic indicator, and these signs are nonspecific.
D. Depressed fontanel and decreased blood pressure
Depressed fontanel and decreased blood pressure is incorrect because a depressed fontanel usually indicates dehydration, not increased ICP, and hypotension is a late and less reliable sign of increased ICP in infants.
Full Explanation
A. Closed fontanel and high-pitched cry is incorrect because a closed fontanel is normal at this age only if ossification is occurring, and a high-pitched cry may indicate pain or neurologic irritation but is not the most specific sign of increased ICP.
B. Bulging fontanel and dilated scalp veins is correct because increased intracranial pressure (ICP) in infants often presents with a bulging, tense fontanel due to accumulation of cerebrospinal fluid, and prominent scalp veins result from increased venous pressure. These are hallmark early signs of hydrocephalus and warrant prompt attention.
C. Constant low-pitched cry and restlessness is incorrect because while irritability and restlessness may accompany increased ICP, a low-pitched cry is not a classic indicator, and these signs are nonspecific.
D. Depressed fontanel and decreased blood pressure is incorrect because a depressed fontanel usually indicates dehydration, not increased ICP, and hypotension is a late and less reliable sign of increased ICP in infants.
A 10-year-old child with a distal femoral fracture involving the growth plate is admitted for treatment. Which nursing action should be prioritized to prevent long-term complications related to growth disturbances?
A. instruct the child to avoid weight-bearing activities indefinitely to prevent fracture displacement.
Instruct the child to avoid weight-bearing activities indefinitely is incorrect because prolonged immobilization is unnecessary and can lead to muscle atrophy and delayed functional recovery. Weight-bearing should be restricted only as medically indicated during the initial healing phase.
B. Assure the parents that damage to the growth plate will not affect the length or shape of the child's limb.
Assure the parents that damage to the growth plate will not affect the length or shape of the child's limb is incorrect because growth plate (physeal) fractures can lead to limb length discrepancies or angular deformities if not properly monitored. Providing false reassurance could delay necessary interventions.
C. Explain that the fracture will heal at the same rate as an adult fracture regardless of age or growth plate involvement.
Explain that the fracture will heal at the same rate as an adult fracture regardless of age or growth plate involvement is incorrect because pediatric fractures involving the growth plate may have unique healing patterns and potential complications, including growth disturbances.
D. Educate the family on the importance of follow-up visits for growth assessment and early detection of limb length discrepancies.
Educate the family on the importance of follow-up visits for growth assessment and early detection of limb length discrepancies is correct because distal femoral physeal fractures carry a high risk for growth disturbances, including limb shortening or angular deformities. Regular follow-up with imaging and growth monitoring allows early identification and intervention, minimizing long-term functional and cosmetic complications.
Full Explanation
A. Instruct the child to avoid weight-bearing activities indefinitely is incorrect because prolonged immobilization is unnecessary and can lead to muscle atrophy and delayed functional recovery. Weight-bearing should be restricted only as medically indicated during the initial healing phase.
B. Assure the parents that damage to the growth plate will not affect the length or shape of the child's limb is incorrect because growth plate (physeal) fractures can lead to limb length discrepancies or angular deformities if not properly monitored. Providing false reassurance could delay necessary interventions.
C. Explain that the fracture will heal at the same rate as an adult fracture regardless of age or growth plate involvement is incorrect because pediatric fractures involving the growth plate may have unique healing patterns and potential complications, including growth disturbances.
D. Educate the family on the importance of follow-up visits for growth assessment and early detection of limb length discrepancies is correct because distal femoral physeal fractures carry a high risk for growth disturbances, including limb shortening or angular deformities. Regular follow-up with imaging and growth monitoring allows early identification and intervention, minimizing long-term functional and cosmetic complications.