A child is being cared for following a head injury. Which of the following findings should indicate to the healthcare provider that the child is developing diabetes insipidus?

Correct Answer: B

Rationale: In a child with a head injury, the development of diabetes insipidus can occur due to pituitary hypofunction, leading to a deficiency of antidiuretic hormone. An elevated sodium level (hypernatremia) is a key finding in diabetes insipidus due to the excessive loss of free water in the urine, resulting in increased sodium concentration in the blood.

Correct Answer: D

Rationale: In this scenario, option D, which is keeping the infant's elbow restrained, is the correct action for the nurse to take. The rationale behind this is that following surgical repair of a cleft lip, it is crucial to prevent the infant from touching or rubbing the surgical site to avoid disruption of the sutures and potential wound complications. Restraining the infant's elbow helps in limiting the infant's movement and reduces the risk of inadvertent injury to the surgical area. Options A, B, and C are incorrect actions for the nurse to take in this situation. Positioning the infant on his abdomen (option A) is not recommended post cleft lip surgery as it can put pressure on the surgical site and may lead to discomfort or disruption of the wound. Cleansing the incision site with hydrogen peroxide (option B) is not advised as it can be harsh on the delicate skin of the infant and may impede the healing process. Offering the infant a pacifier (option C) is also not recommended immediately post cleft lip surgery as sucking on a pacifier may put pressure on the surgical site and interfere with the healing process. In a pediatric nursing context, it is vital for nurses to have a comprehensive understanding of postoperative care following surgical procedures in infants. This includes knowledge of appropriate wound care, positioning, and strategies to prevent complications. By selecting the correct action of keeping the infant's elbow restrained, the nurse demonstrates sound clinical judgment and promotes optimal healing and recovery for the infant post cleft lip surgery.

Correct Answer: C

Rationale: It is essential to give insulin at room temperature to prevent discomfort during administration. Cold insulin can cause stinging and pain, which can be avoided by allowing the insulin to reach room temperature before administration. Storing insulin in the refrigerator is correct for long-term storage, but it should be brought to room temperature before use. Rotating injection sites is important to prevent lipohypertrophy, a condition characterized by fatty lumps that can develop if injections are consistently given in the same area. Administering insulin within 30 minutes of a meal is generally recommended to match the insulin peak action with the peak glucose levels after eating, but giving insulin at room temperature is more crucial to ensure comfort and proper absorption.

Correct Answer: D

Rationale: After a tonsillectomy, applying an ice collar to the child's neck helps decrease pain and swelling. Heat should be avoided as it can increase bleeding. Encouraging coughing may increase the risk of bleeding. Administering analgesics on a regular schedule is essential for pain management, but the immediate postoperative period may require additional interventions like ice collar application.

Correct Answer: C

Rationale: In assessing a child for Kawasaki disease, the correct finding to expect is a fever unresponsive to antipyretics (Option C). Kawasaki disease is characterized by persistent fever lasting more than 5 days, often unresponsive to typical fever-reducing medications. This fever is a hallmark sign of the disease and is crucial for early identification and treatment. Option A, decreased heart rate, is incorrect because Kawasaki disease is associated with tachycardia due to inflammation of the heart and blood vessels. Option B, dry, scaly skin, is incorrect as Kawasaki disease primarily affects the mucous membranes, leading to symptoms like red, cracked lips and a "strawberry" tongue. Option D, nontender cervical lymphadenopathy, is also incorrect as Kawasaki disease is typically associated with tender, enlarged lymph nodes. Educational context: Understanding the key clinical manifestations of Kawasaki disease is vital for pediatric nurses to promptly recognize and intervene in this potentially serious condition. Identifying the characteristic signs and symptoms, such as persistent fever, mucous membrane changes, and lymphadenopathy, is crucial for early diagnosis and appropriate management to prevent complications like coronary artery aneurysms.