Correct Answer: C

Rationale: Nurse Galina should recognize an open anterior fontanel as a normal finding in a 2-year-old child. The anterior fontanel is a soft spot on a baby's skull where the skull bones have not yet fused together. It usually closes by the time a child is 18 to 24 months old. The open fontanel at 2 years of age is within the normal range of closure, and it is not a cause for concern in this case. No need to notify the doctor, look for other signs of abuse, or ask about a family history of Tay-Sachs disease based on this finding.

Correct Answer: B

Rationale: Spastic cerebral palsy is the most common type of cerebral palsy, accounting for around 70-80% of cases. Spastic CP is characterized by stiff, tight muscles that can affect movement and coordination. This type of CP is caused by damage to the motor cortex of the brain, leading to increased muscle tone and difficulty with voluntary movements. Symptoms of spastic CP can vary in severity and may affect one or multiple limbs.

Correct Answer: D

Rationale: In children diagnosed with sickle cell disease (SC
D), tissue damage results from local tissue damage with ischemia and necrosis due to obstructed circulation. Sickle cell disease is a genetic disorder characterized by abnormal hemoglobin that causes red blood cells to assume a sickle shape. These sickle-shaped cells can adhere to blood vessel walls, leading to vaso-occlusion and impaired blood flow. This obstruction results in tissue ischemia and eventual necrosis, causing significant pain and organ damage. The chronic vaso-occlusive events in SCD are responsible for the development of acute and chronic complications seen in affected individuals, such as painful crises, stroke, and organ damage.

Correct Answer: B

Rationale: Airborne isolation is needed for a child hospitalized with chickenpox (varicella) because the virus causing chickenpox spreads easily through the air when an infected person coughs or sneezes. The virus can also be transmitted through direct contact with the rash or fluid from the blisters. By implementing airborne precautions, healthcare providers aim to prevent the spread of the virus to other patients, staff, and visitors in the healthcare setting. In contrast, mumps, exanthema subitum (roseola), and erythema infectiosum (fifth disease) are generally not transmitted through airborne routes; therefore, they do not require airborne isolation in a hospital setting.

Correct Answer: A

Rationale: Furosemide is a loop diuretic commonly used to help the body get rid of excess salt and water through increased urine output. By inhibiting the reabsorption of sodium and chloride in the loop of Henle in the kidneys, furosemide promotes the excretion of water, sodium, chloride, and other electrolytes.
Therefore, the nurse would evaluate the medication as effective if the patient experiences increased urine output, as it indicates that the furosemide is working to eliminate excess fluids from the body.