Burns Pediatric Primary Care Test Bank -Nurselytic

Correct Answer: B

Rationale: The appropriate nursing intervention for a client diagnosed with idiopathic thrombocytopenic purpura (ITP) is administering platelets, as ordered, to maintain an adequate platelet count. ITP is a condition characterized by a decrease in platelet count, which can lead to thrombocytopenia and an increased risk of bleeding. Administering platelets can help prevent excessive bleeding and maintain hemostasis in these patients. Platelet transfusions may be required in severe cases to raise the platelet count to a safe level and prevent bleeding complications. It is crucial for nurses to monitor the platelet count regularly and administer platelets as prescribed to manage ITP effectively.

Correct Answer: D

Rationale: Granulocytic sarcoma is most commonly associated with acute myeloid leukemia (AML).

Correct Answer: D

Rationale: Brown adipose tissue (BAT) is specialized adipose tissue found in newborns and hibernating mammals, whose primary function is to generate heat through non-shivering thermogenesis. This heat generation is essential for maintaining body temperature in newborns, especially as they have a larger surface area-to-volume ratio, which results in greater heat loss compared to adults. BAT produces heat by metabolizing stored lipids and disrupting the normal process of cellular respiration, leading to the production of heat instead of ATP. The heat generated by BAT is then distributed throughout the body to help maintain a stable core body temperature in newborns, who are not yet able to regulate their body temperature as effectively as adults.

Correct Answer: C

Rationale: Changing formula is less critical if the baby is gaining weight adequately.

Correct Answer:

Rationale: Acute glomerulonephritis is characterized by inflammation of the glomeruli in the kidneys, leading to decreased plasma filtration. As a result, fluid volume excess occurs due to impaired kidney function in regulating the fluid balance. Symptoms may include hypertension, edema, weight gain, and oliguria.
Therefore, the most appropriate nursing diagnosis for a child with acute glomerulonephritis would be "Fluid Volume Excess related to decreased plasma filtration". This diagnosis focuses on the pathophysiological process of the condition and helps guide nursing interventions aimed at managing fluid volume overload.