Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A school-age child is admitted in vaso-occlusive sickle cell crisis.
The child’s care should include which intervention? (Select all that apply.)
A. Correction of acidosis
This is wrong because correction of acidosis is not a specific intervention for vaso- occlusive crisis. Acidosis may occur as a complication of sickle cell disease, but it is not the primary cause of the crisis.
B. Adequate hydration.
The management of an acute event of a vaso-occlusive crisis is the use of potent analgesics (opioids), rehydration with normal saline or Ringer’s lactate, treatment of malaria (whether symptomatic or not) using artemisinin combination therapy, and the use of oxygen via face mask, especially for acute chest syndrome.
C. Pain management.
The management of an acute event of a vaso-occlusive crisis is the use of potent analgesics (opioids), rehydration with normal saline or Ringer’s lactate, treatment of malaria (whether symptomatic or not) using artemisinin combination therapy, and the use of oxygen via face mask, especially for acute chest syndrome.
D. Administration of heparin.
This is wrong because the administration of heparin is not recommended for the vaso-occlusive crisis. Heparin is an anticoagulant that may increase the risk of bleeding and does not prevent or treat the sickling process. Normal ranges for hemoglobin are 11.5 to 15.5 g/dl for children after 2 years of age. Normal ranges for reticulocyte count are 0.5% to 1.5% for adults and 0.5% to 2.5% for children.
This question is an excerpt from Nurse Dive's nursing test bank - OB Pediatric Cumulative Exam Test 4 V 1 2023 Proctored Exam. Take the full exam now
Full Explanation
The child’s care should include adequate hydration and pain management. The management of an acute event of a vaso-occlusive crisis is the use of potent analgesics (opioids), rehydration with normal saline or Ringer’s lactate, treatment of malaria (whether symptomatic or not) using artemisinin combination therapy, and the use of oxygen via face mask, especially for acute chest syndrome.
Choice A is wrong because correction of acidosis is not a specific intervention for the vaso- occlusive crisis.
Acidosis may occur as a complication of sickle cell disease, but it is not the primary cause of the crisis.
Choice D is wrong because the administration of heparin is not recommended for the vaso-occlusive crisis.
Heparin is an anticoagulant that may increase the risk of bleeding and does not prevent or treat the sickling process.
Normal ranges for hemoglobin are 11.5 to 15.5 g/dl for children after 2 years of age.
Normal ranges for reticulocyte count are 0.5% to 1.5% for adults and 0.5% to 2.5% for children.
Similar Questions
When caring for a child with Kawasaki disease, the nurse should understand that principle of care?
A. The child’s fever is usually responsive to antibiotics within 48 hours
This is wrong because the child’s fever is usually not responsive to antibiotics within 48 hours. Kawasaki disease is not caused by a bacterial infection, so antibiotics are not effective.
B. The principal area of involvement is the joints
This is wrong because the principal area of involvement is not the joints. Kawasaki disease affects mainly the blood vessels, but it can also cause swelling in glands (lymph nodes) and mucous membranes inside the mouth, nose, eyes and throat. Joint pain or swelling may occur, but it is not the main feature of the disease.
C. Aspirin is contraindicated
This is wrong because aspirin is not contraindicated. Aspirin is part of the standard treatment for Kawasaki disease, along with gamma globulin. However, aspirin should be used with caution and under medical supervision, as it can cause Reye’s syndrome in children with viral infections.
D. Therapeutic management includes the administration of gamma globulin and aspirin.
Therapeutic management includes the administration of gamma globulin and aspirin. This is because Kawasaki disease causes inflammation in the walls of small to medium-sized blood vessels that carry blood throughout the body and can lead to complications such as coronary artery aneurysms. Gamma globulin is an intravenous immunoglobulin that can reduce the risk of these complications, and aspirin can help lower fever and inflammation.
Full Explanation
Therapeutic management includes the administration of gamma globulin and aspirin. This is because Kawasaki disease causes inflammation in the walls of small to medium-sized blood vessels that carry blood throughout the body and can lead to complications such as coronary artery aneurysms. Gamma globulin is an intravenous immunoglobulin that can reduce the risk of these complications, and aspirin can help lower fever and inflammation.
Choice A is wrong because the child’s fever is usually not responsive to antibiotics within 48 hours. Kawasaki disease is not caused by a bacterial infection, so antibiotics are not effective.
Choice B is wrong because the principal area of involvement is not the joints. Kawasaki disease affects mainly the blood vessels, but it can also cause swelling in glands (lymph nodes) and mucous membranes inside the mouth, nose, eyes and throat. Joint pain or swelling may occur, but it is not the main feature of the disease.
Choice C is wrong because aspirin is not contraindicated. Aspirin is part of the standard treatment for Kawasaki disease, along with gamma globulin. However, aspirin should be used with caution and under medical supervision, as it can cause Reye’s syndrome in children with viral infections.
What is the nurse’s first action when planning to teach the parents of an infant with a congenital heart defect (CHD)?
A. Assess the parents’ anxiety level and readiness to learn.
This is because the nurse needs to evaluate the parent’s emotional state and their ability to comprehend and retain information before providing any teaching. The nurse should also consider the parent'slearning style, cultural background, and literacy level.
B. Gather literature for the parents.
This is wrong because gathering literature for the parents is not the first action. The nurse should first assess the parents’ needs and preferences and then select appropriate materials that match their level of understanding and language.
C. Secure a quiet place for teaching
This is wrong because securing a quiet place for teaching is not the first action. The nurse should first assess the parents’ readiness to learn and then choose a suitable environment that minimizes distractions and promotes comfort.
D. Discuss the plan with the nursing team
This is wrong because discussing the plan with the nursing team is not the first action. The nurse should first assess the parents’ anxiety level and readiness to learn and then collaborate with other health care professionals to provide consistent and accurate information.
Full Explanation
Assess the parents’ anxiety level and readiness to learn. This is because the nurse needs to evaluate the parent’s emotional state and their ability to comprehend and retain information before providing any teaching.
The nurse should also consider the parent's learning style, cultural background, and literacy level.
Choice B is wrong because gathering literature for the parents is not the first action. The nurse should first assess the parents’ needs and preferences and then select appropriate materials that match their level of understanding and language.
Choice C is wrong because securing a quiet place for teaching is not the first action. The nurse should first assess the parents’ readiness to learn and then choose a suitable environment that minimizes distractions and promotes comfort.
Choice D is wrong because discussing the plan with the nursing team is not the first action. The nurse should first assess the parents’ anxiety level and readiness to learn and then collaborate with other health care professionals to provide consistent and accurate information.
What is the priority nursing goal for a 14-year-old diagnosed with Graves’ disease?
A. Relieving constipation
This is wrong because relieving constipation is not a priority goal for Graves’ disease. Constipation is more likely to occur in hypothyroidism, which is the opposite of hyperthyroidism.
B. Allowing the adolescent to make decisions about whether or not to take medication
This is wrong because allowing the adolescent to make decisions about whether or not to take medication is not a priority goal for Graves’ disease. While it is important to respect the adolescent’s autonomy and involve them in their care plan, they also need to understand the risks and benefits of taking medication and the consequences of not taking it.
C. Verbalizing the importance of monitoring for medication side effects
Graves’ disease is an autoimmune disorder that causes hyperthyroidism, which means the thyroid gland produces too much thyroid hormone. This can lead to symptoms such as weight loss, increased appetite, nervousness, irritability, insomnia, heat intolerance, and palpitations. The medication methimazole is used to treat Graves’ disease by blocking the synthesis of thyroid hormone. However, methimazole can also cause serious side effects such as liver damage, agranulocytosis (low white blood cell count), and allergic reactions. Therefore, the priority nursing goal for a 14-year-old diagnosed with Graves’ disease is to verbalize the importance of monitoring for medication side effects and reporting them to the health care provider.
D. Developing alternative educational goals
This is wrong because developing alternative educational goals is not a priority goal for Graves’ disease. Graves’ disease can affect the academic performance of adolescents due to cognitive and emotional changes caused by hyperthyroidism. However, this does not mean that they need to change their educational goals. They may need extra support and accommodations from their teachers and parents to cope with their condition and achieve their potential.
Full Explanation
Verbalizing the importance of monitoring for medication side effects.
Graves’ disease is an autoimmune disorder that causes hyperthyroidism, which means the thyroid gland produces too much thyroid hormone. This can lead to symptoms such as weight loss, increased appetite, nervousness, irritability, insomnia, heat intolerance, and palpitations. The medication methimazole is used to treat Graves’ disease by blocking the synthesis of thyroid hormone. However, methimazole can also cause serious side effects such as liver damage, agranulocytosis (low white blood cell count), and allergic reactions.
Therefore, the priority nursing goal for a 14 year old diagnosed with Graves’ disease is to verbalize the importance of monitoring for medication side effects and reporting them to the health care provider.
Choice A is wrong because relieving constipation is not a priority goal for Graves’ disease. Constipation is more likely to occur in hypothyroidism, which is the opposite of hyperthyroidism.
Choice B is wrong because allowing the adolescent to make decisions about whether or not to take medication is not a priority goal for Graves’ disease. While it is important to respect the adolescent’s autonomy and involve them in their care plan, they also need to understand the risks and benefits of taking medication and the consequences of not taking it.
Choice D is wrong because developing alternative educational goals is not a priority goal for Graves’ disease. Graves’ disease can affect the academic performance of adolescents due to cognitive and emotional changes caused by hyperthyroidism.
However, this does not mean that they need to change their educational goals. They may need extra support and accommodations from their teachers and parents to cope with their condition and achieve their potential.