nursing diagnosis and interventions for peds test 1 – Flashcards

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question
Encephalitis nursing dx
answer
ineffective tissue perfusion r/t inflamed cerebral tissues and meninges, Excess fluid volume r/t ICP, Risk for injury r/t seizure, Altered protection r/t immature immune system, Decreased intracranial adaptive capacity, Inefective airway clearance r/t seizure activity
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Epiglottitis Nursing dx
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ineffective airway clearance, fear/anxiety, activity intolerance, pain, altered family process
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Nursing interventions for Acute Resp Distress
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oxygenation, prevent infection, adequate hydration and nutrition, comfort, psychological support
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What priority nursing interventions are appropriate when caring for a child with bacterial meningitis?
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As soon as meningitis is suspected the child should be put on isolation precautions (airborne) and the nurse need to administer the antibiotics as quickly as possible. However, all cultures need to be obtained before antibiotics are given. Antibiotics are the main line of defense against the bacteria.
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Ineffective tissue perfusion r/t inflamed cerebral tissues and meninges, ICP How would you evaluate this nursing dx? Would you assess pulses and cap refills?
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Nooooo. That is tissue perfusion peripheral, tissue perfusion cerebral needs to be evaluated with LOC, pupil changes, etc.
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What nursing interventions should be implemented for a child who is post-op for removal of a brain tumor?
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Do not place the child on the operative site. The book says to have the bed flat for infratentorial tumors and elevated for supratentorial tumors. In practice, the head of the bed is elevated for all tumors. Make sure the head is midline for drainage. Watch VS and neuron status as well as for seizure activity. Do not remove the dressing, but reinforce if needed.
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What considerations should the nurse include in the care of a child with spina bifida?
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Because of the defect, the normal flow of spinal fluid is interrupted leading to hydrocephalus. The nurse needs to assess for increasing ICP. Need to implement latex allergy precautions and order a latex free cart.
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Nursing dx for nephrotic syndrome
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Fluid volume deficit r/t osmotic shift to third space, Fatigue r/t disease process, Impaired protection r/t renal impairment, Altered skin integrity r/t massive edema, Altered family process r/t illness and hospitalization
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What is the first line drug for nephrotic syndrome and what is the rational for its use? How long will this drug be given?
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Prednisone because this is an autoimmune disease process. It is given for 10 days after the urine is free of protein. It is restarted if the patient relapses and protein begins to be lost again.
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Nephrotic syndrome What treatments should the nurse expect to be ordered to treat Jimmy's massive edema and third spacing and why?
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albumin infusion to replace the loss of the plasma protein, which will draw the water from the third space to the vascular space. Lasix is then given to dieresis the patient and remove the fluid. These can be given as simultaneous infusions (in separate IVs of course) or can give the albumin over a couple of hours and give the Lasix dose after it.
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Acute Glomerulonephritis nurs dx
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Fluid volume excess r/t decreased plasma filtration, Altered family process r/t acute illness, Risk for infection r/t renal impairment
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Acute Glomerulonephritis What physician orders should the nurse anticipate? Provide a rationale.
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sodium restriction (no added salt) - to prevent further fluid retention, fluid restriction - prevent further fluid overload, medications such as antihypertensives, diuretic - to dieresis and treat hypertension due to fluid overload
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Gastroschisis nurs dx
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Impaired protection r/t exposed organs. Impaired nutrition. Impaired development.
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Resp failure nurs dx
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Ineffective gas exchange, Decreased cardiac output, Ineffective breathing pattern r/t neuro compromise from lack of oxygen, Ineffective airway clearance r/t fluid in lungs, Interrupted family processes
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Which is a symptom of overhydration?
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Respiratory distress
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A 4 month old is admitted for a GI virus causing diarrhea and vomiting. The child is lethargic, Na level 142, dry mucous membranes, 12% weight loss & sunken fontanel. What type of dehydration is this child experiencing? Question 2 options: A) Moderate isotonic dehydration B) Mild hypotonic dehydration C) Moderate hypertonic dehydration
answer
a
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A child is brought to the ER for 4 day history of vomiting. They are restless and reports that their feet and hands feel asleep. ABG reveals pH 7.48, PCO2 46, HCO3 35. What is this child experiencing? Question 3 options: A) Metabolic acidosis B) Respiratory acidosis C) Metabolic alkalosis D) Respiratory alkalosis
answer
c
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Which of the following is an appropriate nursing action when caring for a newborn with esophageal atresia/ TE fistula? Question 4 options: A) Lay baby in prone position B) Maintain desired temp of 96.5 C) Suction every 4 hours D) Give initial feeding of sterile water
answer
d
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When esophageal atresia/TE fistula is suspected, the nurse should...? Question 5 options: A) Feed the baby carefully looking for symptoms B) Keep the baby NPO and maintain IV nutrition C) Allow the parents to have the baby room in
answer
b
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Which of the following is a priority nursing diagnosis for the baby with esophageal atresia/TE fistula? Question 6 options: A) Imbalanced nutrition r/t inability to feed B) Altered family process r/t newborn illness C) Ineffective Airway Clearance r/t copious secretions D) Risk for altered infant bonding r/t inability to feed
answer
c
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What is the priority nursing diagnosis for a newborn with gastroschisis? Question 7 options: A) Hyperthermia r/t exposed organs B) Impaired protection r/t exposed organs C) Delayed growth & development r/t prolonged illness
answer
b
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Which child would be suspected of having biliary atresia? Question 8 options: A) A 3 week old with yellow watery diapers with strikes of blood B) A 2 week old with jaundice and weight below birth weight C) A 4 week old who is difficult to sooth after eating
answer
b
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Which child is most likely to have celiac disease? Question 9 options: A) 4 year old with 1 week history of diarrhea and 2 pound weight loss B) A 10 year old with vomiting and bloody diarrhea and 20 pound weight loss over last month C) A 3 year old with distended belly, foul smelling stools, and decreased serum albumin
answer
c
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What is the priority nursing diagnosis for an infant with biliary atresia? Question 10 options: A) Imbalanced nutrition less than body requirements r/t poor absorption B) Impaired comfort r/t jaundice C) Delayed growth and development r/t decreased nutrition
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a
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The major source of nutrition for short bowel babies is through...? Question 12 options: A) IV hyperallimentation B) GT feedings C) Oral feedings
answer
a
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Which of the following is a priority nursing diagnosis for a child with short bowel syndrome? Question 13 options: A) Delayed growth & development r/t decreased nutrition B) Impaired nutrition r/t decreased absorption C) Risk for infection r/t invasive lines and high glucose solutions D) Risk for impaired skin integrity r/t diarrhea
answer
b
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Which of the following is part of post-op care for a baby with esophageal atresia/TE fistula? (may have more than one answer) Question 14 options: A) Initiate feeds with sterile water about 2 weeks after surgery B) Restart GT feeds as soon as return from surgery C) Assess for signs of respiratory distress with feeds
answer
a,c
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Which nursing actions are important when caring for a newborn? (multiple answers) Question 15 options: A) Put in prone position B) Report if no stool in 24 hours of birth C) Assess orifice from which meconium appears
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b,c
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Which of the following are appropriate nursing actions when caring for a baby with omphalocele or gastroschisis? (multiple answers) Question 16 options: A) Sterile saline soaks to defect B) Bottle feed breast milk 30 ml every 2 hours C) Radiant warmer
answer
a,c
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Which child would be most likely to develop short bowel syndrome? (multiple answers) Question 17 options: A) 2 week old with large portion of bowel removed due to necrosis related to gastroschisis B) 7 day old with NEC requiring removal of 50% of small bowel and colostomy C) 4 month old baby who was victim of child abuse requiring removal of 75% of small bowel
answer
a,b,c
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What are the major goals of treatment for a child with short bowel syndrome? (multiple answers) Question 18 options: A) Maintain adequate nutrition B) Only give oral feedings C) Foster growth and development D) Prevent infections
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a,c,d
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What is a major complication for children with short bowel syndrome? (multiple answers) Question 19 options: A) Aspiration pneumonia B) Liver failure C) CVL line infection D) Colostomy skin care
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b,c
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Which of the following is essential to include in discharge teaching for a child with short bowel syndrome? (multiple answers) Question 20 options: A) Decreased stimulation B) Care of the CVL C) Solutions to manage irritability D) GT site care
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b,d
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Give an example of an insensible water loss in children.
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Fever, perspiration, respiratory tract, watery stools
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What are the clinical signs & symptoms that would make the nurse suspect esophageal atresia or TE fistula?
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3 C's - coughing, choking, cyanosis, apnea, respiratory distress after feeding, abdominal distention
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