HESI Case Studies–Pediatrics-Cystic Fibrosis (Debbie Baker) – Flashcards
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1. Which statement by the mother supports the diagnosis of CF?
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"When I kiss my daughter, her skin tastes like salt."
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2. Which documentation further supports the diagnosis of CF? (Select all)
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-A history of frequent respiratory infections -Reports of foul-smelling stools that have white streaks and are sticky
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3. What information will the nurse include when teaching about the sweat test?
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It is a simple, painless, reliable test that measures the chloride in sweat.
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4. David expresses concern to the nurse that Paula hasn't accepted Debbie's diagnosis. What action should the nurse take first?
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Make arrangements to meet with Paula privately at the first opportunity
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5. What response reflects that the nurse values the principle of beneficence?
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"Paula, I know this has to be a very scary and difficult time for you. What can I do to help you?"
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6. David is concerned that his wife is going to leave him. What is the best response by the nurse?
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"I will sit with Debbie so you and your wife can talk. We have a quiet room you can use that is private and close by."
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7. Which nursing diagnosis has the highest priority?
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Altered nutrition: less than body requirements related to poor intestinal absorption
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8. Which statement should the nurse record as the expected outcome for this nursing diagnosis?
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The child will be able to remove mucus from the airway by coughing
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9. The student nurse asks, "I keep hearing about standards of care. What are standards of care?" The nurse provides which explanation?
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Standards of care are published statements that describe the level of care that the client with cystic fibrosis (or other diseases) can expect from nurses
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10. The student nurse asks, "What type of care is given in secondary nursing care?" Which statement by the nurse is correct?
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"It is care such as vision, hearing, and scoliosis screening that Debbie will get when she starts school."
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11. Which statement indicates a correct understanding of the etiology of CF?
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Both of Debbie's biological parents must have the CF gene for Debbie to get it
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12. Which instruction should the Nurse Educator include when discussing respiratory complications?
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Perform chest percussion and postural drainage 2 times a day
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13. Which intervention should the Nurse Educator discuss with Debbie's parents?
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Discuss the importance of playing games that require Debbie to do physical activity such as running, jumping, or skipping
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14. What actions should the nurse educator take to address this? (Select all)
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-Teach Debbie to take a deep breath and the exhale when whispering the word "huff." -Instruct the parents to perform chest physiotherapy (CPT) either 1 hour before meals or 2 hours after meals, if possible -Explain the importance of increasing fluid intake during acute exacerbations
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15. Which instruction should the Nurse Educator give Debbie's parents concerning the use of pancreatic enzymes as an oral prescription?
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Open the capsules and mix the beads in a nonprotein food such as applesauce
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16. Which adjustment will be required if Debbie has loose, fatty stools?
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Increase the pancreatic enzymes with each meal and snack
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17. Which rationale best supports this referral?
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Community resources often provide support groups for parents of children with CF
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18. Debbie is able to say her first and last names, and to state her age while holding up 3 fingers. What action by the nurse is warranted?
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Document the observations but take no action at this time
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19. Paula asks the nurse, "What is play therapy?" What is the best response by the nurse?
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"Play therapy uses toys and games to help with Debbie's physical and emotional needs."
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20. What is the Nurse Educator's responsibility when discussing immunizations?
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Explain that Debbie should receive all routine childhood immunizations
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21. Paula asks, "When should the second MMR be given to Debbie?" What response is most appropriate by the primary nurse?
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"The second MMR is given between 4 and 6 years of age."
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22. What laboratory result warrants immediate intervention?
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White blood cell count (WBC) is 20,000mm^3
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23. Which intervention should the nurse implement first?
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Administer oxygen 6L/min via simple face mask
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24. At what rate should the nurse set the infusion pump?
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25. Which action should the primary nurse implement first?
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Assess Debbie and the child that received the wrong medication
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26. What nursing task can be safely delegated to the UAP?
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Empty the Foley bag
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27. What action should the charge nurse take?
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Explain the play therapy is an intervention and should not be interrupted for vital signs
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28. How should the Nurse Educator respond?
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Suggest that they add extra salt to Debbie's diet and watch for dehydration
