NURSING 1010 Assessment- Rationales RN VATI Nursing Care of Children 2016 UPDATED

Assessment- Rationales RN VATI Nursing Care of Children 2016 2. "Your child will be exposed to a moderate amount of radiation during the procedure." MY ANSWER An MRI produces radiofrequency emissions from nonradioactive elements; therefore, there is no exposure to radiation involved during this procedure. "Your child might experience pain during the procedure." An MRI does not cause pain, as it is a noninvasive procedure that emits radiofrequencies to produce an image. "This is considered an invasive procedure." An MRI is a noninvasive procedure, unless an IV is prescribed when contrast is used. No contrast is indicated for this child, so no IV is needed. "You can remain in the room with your child during the procedure." The parent may remain in the room with the child to provide comfort and reassurance during the procedure. 3. Nausea The nurse should identify that nausea is an early sign of increased intracranial pressure in a child. Papilledema The nurse should identify that papilledema is a late sign of increased intracranial pressure in a child. Dilated pupils The nurse should identify that dilated pupils along with a decreased pupillary response are late signs of increased intracranial pressure in a child. Bradycardia MY ANSWER The nurse should identify that bradycardia is a late sign of increased intracranial pressure in a child. 4. Initiate contact precautions. The nurse should initiate contact, droplet, and standard precautions for RSV because exposure to contaminated secretions can transmit the virus. RSV can live on objects for several hours and on hands for 30 min. Perform chest percussion and postural drainage. The nurse should perform periodic suctioning of the nose or nasopharynx to clear nasal secretions. Chest percussion and postural drainage are not routinely recommended for an infant who has RSV. Encourage clear liquids by mouth. MY ANSWER The nurse should not encourage clear liquids by mouth, because the infant has tachypnea. Oral fluids are contraindicated in the presence of tachypnea due to the risk for aspiration. Administer IV antibiotics. The nurse should not plan to administer IV antibiotics, because RSV is a viral infection. Antibiotics may be prescribed if a secondary bacterial infection occurs. 5. Warm extremities Heart failure involves an inability of the heart to pump effectively, limiting perfusion to major organs and the extremities. The nurse should expect a child who has heart failure to exhibit pale, cool extremities. Frequent headaches The child who has heart failure can exhibit neurologic manifestations, such as increased restlessness or irritability as a result of hypoxia and impaired cardiac function; however, frequent headaches are not an expected manifestation associated with heart failure. Distended neck veins The child who has heart failure will exhibit manifestations of increased blood volume, such as distended neck veins. This occurs because the hormone ADH is excreted, which holds onto sodium and water in response to decreased cardiac output and renal perfusion. Weight loss MY ANSWER The child who has heart failure will exhibit weight gain as a result of sodium and water retention. As the heart failure progresses, dependent and periorbital edema, ascites, and pulmonary effusions result. 6. The infant falls to a sitting position while learning how to walk. The infant falling to a sitting position while learning how to walk is not a manifestation of hemophilia, as this is an expected part of growth and development. The infant bleeds slightly when scratched by a cat. Bleeding slightly when a minor scratch occurs is not a manifestation of hemophilia; however, if the bleeding is not easily controlled, the parent should notify the provider. The infant's skinned knee drains serosanguineous fluid. MY ANSWER The drainage of serosanguineous fluid from a skinned knee is not a manifestation of hemophilia. This is an expected finding after a skin injury and does not warrant evaluation. The infant's knees are reddened and edematous. The nurse should identify that the infant might be experiencing hemarthrosis if redness, edema, and warmth of the joints are noted. Bleeding into the joints is the most frequent form of internal bleeding in children who have hemophilia. "I should eat extra food on busy days when I am more active" is correct. The nurse should instruct the child to increase her intake of allowable foods when she is more active. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. "I should wait 2 hours after eating before playing with my friends" is incorrect. The child should play or exercise within 2 hr of eating because exercise requires her to have more carbohydrates in her system. Waiting 2 hr after eating before play or exercise increases the likelihood of a hypoglycemic episode. A carbohydrate snack will most likely be needed during prolonged play or exercise and another a few hours after the activity. "I should increase my intake of sugar-free fluids when I am sick" is correct. The nurse should instruct the child to increase her intake of sugar-free fluids when she is sick. Fluids flush out ketones to prevent dehydration. The nurse should recommend sugar-free liquids, such as water, broth, and tea to the child. The child should continue with her usual intake at mealtimes and follow her recommended meal plan as much as possible. "I should eat a snack 30 minutes before my baseball game starts" is correct. The nurse should instruct the child to eat a recommended snack 30 min prior to a planned activity, such as a baseball game. If the game is prolonged, she should have a snack every 45 min to an hour. If for some reason the child cannot tolerate the extra food, the next intervention is to decrease the child's insulin dose before baseball games. "I should have a 16 ounce sports drink if I start feeling weak or shaky" is incorrect. The child should consume 8 oz of a sports drink if she feels hypoglycemic, rather than 16 oz. Clinical manifestations of hypoglycemia include dizziness, headache, irritability, weakness, shakiness, and confusion. An 8-oz sports drink contains 15 g of carbohydrate. If the child consumes 16 oz, it would contain a minimum of 30 g of carbohydrate and most likely cause the child to become hyperglycemic and require a dose of insulin. 8. "Your child's skin will appear flushed." MY ANSWER The nurse should inform the parents that their child will have pale skin near the end of his life. The skin is cool to the touch and might appear grayish-blue as death nears. Mottling might occur in the extremities and move toward the body core because of a decrease in cardiac output and perfusion to the extremities. "Your child will lose movement in his legs." The nurse should inform the parents that their child will lose movement of the lower extremities. This progressive loss of movement will move up the body as death nears. "Your child will first lose his ability to hear." The nurse should inform the parents that the sense of hearing is the last sense to fail as death nears. Loss of sensation develops before hearing loss, and the child might become more sensitive to light. "Your child's blood pressure will start to increase." The nurse should inform the parents that their child will experience decreased cardiac output, leading to a drop in blood pressure and decreased pulses. Koplik spots The nurse should not expect a child who has viral meningitis to have Koplik spots. Koplik spots are small red spots with a white center that are found on the oral mucosa in children who have measles. Decreased protein in the cerebrospinal fluid The nurse should expect a child who has viral meningitis to exhibit either a normal or slightly elevated protein level in the cerebrospinal fluid due to increased permeability of the blood-brain barrier. Nuchal rigidity MY ANSWER The nurse should expect a child who has viral meningitis to have nuchal rigidity, which is caused by meningeal irritation. The child might also have fever and photophobia. Decreased glucose in the cerebrospinal fluid The nurse should expect a child who has viral meningitis to exhibit a glucose level in the cerebrospinal fluid within the expected reference range. Bacterial meningitis can decrease the glucose in the cerebrospinal fluid. 11. Restrict the child's potassium intake. MY ANSWER The nurse should not instruct the parents to restrict the child's potassium intake; however, the parents should restrict the child's sodium intake by avoiding the addition of salt to the child's food and eliminating high-sodium foods from the diet. The child may resume a regular salt intake after the acute phase of nephrotic syndrome has passed. Provide quiet activities for the child. The nurse should instruct the parents to provide quiet activities, such as reading and coloring, during the edema phase of nephritis to minimize oxygen consumption and preserve energy. Weigh the child once a week. The nurse should instruct the parents to weigh the child at the same time each day with the child wearing the same clothing. The nurse should instruct the parents to notify the provider if the child's weight increases. Administer acetaminophen to the child daily. The nurse should not instruct the parents to administer acetaminophen to the child daily, as nephrotic syndrome does not cause pain. Daily administration of acetaminophen could also cause additional stress to the child's kidneys. 12. "I will cook foods that are low in fat and carbohydrates." The parent should serve nutritious foods that are high in calories, protein, and fats. A child who has cystic fibrosis experiences intestinal malabsorption and is at risk for nutritional deficiencies and inadequate growth. "My child can chew his enzyme medication with meals." The parent should have the child swallow the capsules whole or sprinkle them on his food within 30 min of her meals and snacks. The child should not chew or crush the enteric-coated tablets, because destroying the enteric coating can lead to inactivation of the enzymes and excoriation of the oral mucosa. "I will give my child stool softeners for constipation." Constipation can occur in the child who has cystic fibrosis because of a failure to properly break down foods, a slowing of the intestinal motility, and the thickened enzymatic secretions due to the disease process itself. The parent should administer an osmotic solution, such as polyethylene glycol, stool softeners, or laxatives to treat constipation. "My child will be excused from physical education class." MY ANSWER The parent should encourage the child to participate in physical exercise to mobilize secretions and increase blood flow to the lungs. Exercise can stimulate mucus excretion and provides a sense of good health and positive self-esteem for the child. 13. Administer factor VIII is correct. Hemophilia A is a bleeding disorder caused by a factor VIII deficiency; therefore, the nurse should plan to administer factor VIII prophylactically to prevent or minimize bleeding. Assess for changes in level of consciousness is correct. Hemophilia A can cause cerebral bleeding; therefore, the nurse should assess the child for headaches and decreased level of consciousness. Apply a warming blanket over the child is incorrect. The nurse should apply ice or cold packs to the child to vasoconstrict the child's blood flow. Perform passive range of motion hourly is incorrect. The nurse should rest the joints during the acute phase of bleeding to prevent stretching the joint or bleeding to recur. Refrigerate the reconstituted antihemophilic factor solution until used. While the factor VIII concentrate (unreconstituted) should be stored in the refrigerator, once it is mixed with the diluent, it should not be returned to the refrigerator. Administer factor IX is incorrect. The nurse should identify that children who ha...

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