A nurse is assisting in the care of a child in the pediatrician's office.
bone marrow failure
hypernatremia
malabsorption
chronic respiratory infections
excessive weight gain
Correct Answer : C,D
Rationale:
• Chronic respiratory infections: A positive sweat chloride test confirms cystic fibrosis, a condition characterized by thick mucus that obstructs airways, leading to persistent cough, wheezing, and a high risk of recurrent lung infections due to impaired mucus clearance.
• Malabsorption: Cystic fibrosis affects the pancreas by blocking enzyme flow needed for digestion. This results in poor nutrient absorption, causing symptoms like excessive hunger, weight loss despite eating well, and abdominal distension, all of which are evident in this child.
• Bone marrow failure: There are no signs of pancytopenia, anemia, or infection susceptibility that would suggest bone marrow dysfunction. Cystic fibrosis does not typically impact hematopoietic function directly.
• Hypernatremia: Although cystic fibrosis can lead to salt imbalances due to abnormal chloride transport, hypernatremia is not commonly a presenting concern unless there's severe dehydration, which is not evident here.
• Excessive weight gain: The child is losing weight despite increased appetite. Malabsorption from pancreatic insufficiency prevents weight gain in cystic fibrosis, making excessive weight gain an unlikely risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Instruct the client to lie supine with his knees flexed: Flexing the knees reduces tension on the abdominal wall and helps prevent further protrusion of abdominal contents. This position is critical for stabilizing the evisceration while awaiting surgical intervention.
B. Cover the wound with a dry sterile dressing: Using a dry dressing can cause the exposed organs to dry out and adhere to the material, increasing the risk of tissue damage. A moist sterile dressing is needed to protect and preserve the protruding tissues.
C. Position the client in semi-Fowler's position: Elevating the head of the bed increases intra-abdominal pressure and can worsen evisceration. This position should be avoided to prevent strain on the open surgical site.
D. Cover the wound with a transparent dressing: Transparent dressings are not suitable for eviscerations because they do not provide adequate moisture or protection for exposed organs. A sterile saline-moistened dressing is required to maintain tissue integrity.
Correct Answer is D
Explanation
Rationale:
A. Start using a highchair for feedings: Infants typically begin using a highchair around 6 months of age when they can sit unsupported. At 3 months, using a highchair is unsafe as the infant lacks sufficient head and trunk control.
B. Place no more than one small pillow in the crib: Pillows and soft bedding increase the risk of suffocation and sudden infant death syndrome (SIDS). The safest practice is to keep the crib free of pillows, blankets, and other soft items.
C. Make sure the crib mattress is soft: A firm crib mattress is recommended to reduce the risk of suffocation and SIDS. A soft mattress can create indentations that pose hazards for infants.
D. Remove bibs when the infant is going to sleep: Bibs can become choking or strangulation hazards during sleep. Removing them before sleep reduces the risk of airway obstruction and promotes infant safety.
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