Question

A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take

Answer 1

Correct Answers:

Wrap the arm of the child's doll or toy prior to the procedure.

Rationale :

🌟 Preschoolers are in the preoperational stage (ages 3–6), where they learn best through play and demonstration. Wrapping a doll’s arm first helps reduce fear, builds trust, and promotes cooperation.

🌟 Supporting the arm should be done gently with open palms, not a firm grasp, to avoid discomfort while the cast is applied.

🌟 Using a heated fan is unsafe because casts must dry naturally; added heat can cause burns or lead to uneven cast hardening.

🌟 Telling the child “this will make your arm feel better” is misleading and does not provide appropriate preparation for the procedure.

🌟 Using a therapeutic play approach helps the child feel safe, understand the process, and cope better with medical procedures.

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Answer 2

Correct Answers:

Modify the environment.

Rationale :

💠 A child with hemiplegic cerebral palsy has paralysis or significant weakness on one side of the body, which places them at high risk for injury in the home.

💠 The priority goal is to ensure safety by modifying the environment (removing hazards, adding adaptive equipment, ensuring accessible spaces).

💠 While fostering self-care, improving communication, and providing respite services are all important long-term goals, they do not take precedence over preventing injury and ensuring a safe environment.

💠 Safety and accessibility form the foundation of the care plan, allowing other goals to be achieved effectively.

💠 This aligns with Maslow’s hierarchy, where physiological needs and safety come before social or developmental goals.

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Answer 3

Correct Answers:

Notify the surgeon

Rationale :

🔶 Colorless (clear) drainage from a surgical site after brain tumor removal suggests cerebrospinal fluid (CSF) leakage, which is a medical emergency.

🔶 CSF leaks increase the risk for meningitis, intracranial infection, and impaired healing.

🔶 The nurse should not only document or monitor, as this delays urgent intervention.

🔶 Reinforcing the dressing may temporarily cover the leak but does not address the life-threatening risk.

🔶 Prompt notification of the surgeon ensures immediate evaluation and intervention to protect the child from complications.

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Answer 4

Correct Answers:

Notify the surgeon

Rationale :

🔶 Colorless (clear) drainage from a surgical site after brain tumor removal suggests cerebrospinal fluid (CSF) leakage, which is a medical emergency.

🔶 CSF leaks increase the risk for meningitis, intracranial infection, and impaired healing.

🔶 The nurse should not only document or monitor, as this delays urgent intervention.

🔶 Reinforcing the dressing may temporarily cover the leak but does not address the life-threatening risk.

🔶 Prompt notification of the surgeon ensures immediate evaluation and intervention to protect the child from complications.

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Answer 5

Correct Answers:

Provide 100% humidified oxygen.

Rationale :

⭐ With facial burns, there is a high risk of airway compromise due to inhalation injury, swelling, and potential obstruction.

⭐ The highest priority in emergency burn management follows the ABC rule (Airway, Breathing, Circulation), making oxygen administration and airway support the first intervention.

⭐ Clothing removal, pain management, and burn cooling are all important but come after airway stabilization.

⭐ Early oxygen administration prevents hypoxemia and respiratory distress, which can rapidly become life-threatening.

⭐ Inhalation injury is the leading cause of mortality in burn patients, so airway protection always comes first.

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Answer 6

Correct Answers:

Inability to move extremity
Severe pan not relieved by analgesics
Tingling of extremity

Rationale :

🟣 Inability to move extremity

♦️Loss of movement is a late but serious sign of neurovascular compromise in compartment syndrome.

♦️It indicates that increasing pressure within the closed fascial space is impairing nerve and muscle function.

♦️Immediate action is required to prevent permanent disability or loss of limb.

🟣 Severe pain not relieved by analgesics

♦️Unrelenting pain, especially pain that is disproportionate to the injury or not relieved by opioids, is a hallmark sign of compartment syndrome.

♦️This occurs because of ischemia from restricted blood flow, causing tissue hypoxia and nerve compression.

♦️Pain is often worsened with passive stretching of the muscles in the affected compartment.

🟣 Tingling of extremity

♦️Tingling or paresthesia reflects early nerve compression and ischemia within the affected compartment.

♦️It signals that sensory nerves are being compromised before motor function is completely lost.

♦️Without intervention, this can progress to numbness and paralysis.

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Answer 7

Correct Answers:

Do not make adjustments on the harness.

Rationale :

💠 The Pavlik harness is used to keep the infant’s hips in proper flexion and abduction to promote normal hip development in developmental dysplasia of the hip (DDH).

💠 Only the healthcare provider should make adjustments, since improper positioning can cause circulatory compromise, nerve damage, or impaired hip development.

💠 Parents should be taught how to maintain skin integrity by placing the diaper under the straps, not over, and using thin superabsorbent diapers to minimize bulk.

💠 Lotion or powder should not be applied because they can irritate the skin and increase risk of breakdown under straps. Instead, clothing or soft liners can be used for protection.

💠 The harness should not be removed daily unless prescribed; prolonged removal may interfere with hip stabilization.

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Answer 8

Correct Answers:

Lethargy

Rationale :

🌟 Hypothyroidism results from decreased production of thyroid hormones, leading to a slowed metabolic rate.

🌟 Clients commonly present with lethargy, fatigue, cold intolerance, weight gain, constipation, bradycardia, and dry skin.

🌟 Exophthalmos is associated with hyperthyroidism (Graves’ disease), not hypothyroidism.

🌟 Photophobia is linked to eye disorders or hyperthyroid eye disease, not hypothyroidism.

🌟 Weight loss is typical of hyperthyroidism due to increased metabolism, while hypothyroidism typically causes weight gain.

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Answer 9

Correct Answers:

use language that is age appropriate for the child.

Rationale :

🔷 A 6-year-old is in the school-age stage of development (concrete operational thinking) and benefits most from clear, simple, and age-appropriate explanations.

🔷 Using words and concepts the child understands helps reduce fear and anxiety, builds trust, and promotes cooperation during painful or unfamiliar procedures.

🔷 Avoiding details may increase anxiety because children often imagine something worse than reality.

🔷 Promising rewards for not crying is inappropriate, as crying is a natural response and should not be discouraged through bribery.

🔷 Painful procedures should never be explained as being done without pain medication if analgesia or comfort measures are available, as this undermines trust.

🔷 Age-appropriate communication is a cornerstone of therapeutic pediatric nursing care.

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Answer 10

Correct Answers:

A child who has rheumatic fever

Rationale :

💠 A child with leukemia is immunocompromised due to both the disease and treatment (chemotherapy, radiation). They should not be placed with clients who have infectious conditions.

💠 Nephrotic syndrome and cystic fibrosis increase infection risk and could expose the immunocompromised child to harmful pathogens.

💠 A child recovering from a ruptured appendix may still harbor infection risk (peritonitis, abscess).

💠 Rheumatic fever is an inflammatory condition following a streptococcal infection, not contagious at this stage, making this the safest roommate choice.

💠 Priority is always to protect the immunocompromised child from infection exposure while also considering safety for the other child.

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QLexNursing

1 :
A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take

2 :
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

3 :
A nurse is caring for a school-age child following the removal of a brain tumor. Colorless drainage is noted on the surgical dressing. Which is the priority action by the nurse?

4 :
A nurse is caring for a school-age child following the removal of a brain tumor. Colorless drainage is noted on the surgical dressing. Which is the priority action by the nurse?

5 :
An adolescent is admitted in the emergency department after being trapped in a garage fire at home. Partial-thickness burns are present on the side of the face, as well as on both arms. Which nursing action is the highest priority?

6 :
The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply.)

7 :
The nurse is teaching a family how to care for an infant in a Pavlik harness to treat developmental dysplasia of the hip. Which of the following statements should the nurse include in discharge teaching?

8 :
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

9 :
The nurse in a pediatric oncology unit understands that painful tests and treatments are common for children with cancer. Which Of the following is an appropriate nursing action to assist with pain management for a 6-year-old client scheduled for diagnostic testing?

10 :
A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

QLexNursing

1 : A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take

2 : A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

3 : A nurse is caring for a school-age child following the removal of a brain tumor. Colorless drainage is noted on the surgical dressing. Which is the priority action by the nurse?

4 : A nurse is caring for a school-age child following the removal of a brain tumor. Colorless drainage is noted on the surgical dressing. Which is the priority action by the nurse?

5 : An adolescent is admitted in the emergency department after being trapped in a garage fire at home. Partial-thickness burns are present on the side of the face, as well as on both arms. Which nursing action is the highest priority?

6 : The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply.)

7 : The nurse is teaching a family how to care for an infant in a Pavlik harness to treat developmental dysplasia of the hip. Which of the following statements should the nurse include in discharge teaching?

8 : A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

9 : The nurse in a pediatric oncology unit understands that painful tests and treatments are common for children with cancer. Which Of the following is an appropriate nursing action to assist with pain management for a 6-year-old client scheduled for diagnostic testing?

10 : A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?

1 :
A nurse is preparing to assist with applying a cast to a preschooler's arm. Which of the following actions should the nurse take

2 :
A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

3 :
A nurse is caring for a school-age child following the removal of a brain tumor. Colorless drainage is noted on the surgical dressing. Which is the priority action by the nurse?

4 :
A nurse is caring for a school-age child following the removal of a brain tumor. Colorless drainage is noted on the surgical dressing. Which is the priority action by the nurse?

5 :
An adolescent is admitted in the emergency department after being trapped in a garage fire at home. Partial-thickness burns are present on the side of the face, as well as on both arms. Which nursing action is the highest priority?

6 :
The nurse is caring for a preschool child with a cast applied recently for a fractured tibia. Which assessment findings indicate possible compartment syndrome? (Select all that apply.)

7 :
The nurse is teaching a family how to care for an infant in a Pavlik harness to treat developmental dysplasia of the hip. Which of the following statements should the nurse include in discharge teaching?

8 :
A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

9 :
The nurse in a pediatric oncology unit understands that painful tests and treatments are common for children with cancer. Which Of the following is an appropriate nursing action to assist with pain management for a 6-year-old client scheduled for diagnostic testing?

10 :
A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child?