A nurse is caring for a child who has a recent history of a concussion. Which of the following is a priority assessment?

Correct Answer: A

Rationale: In the context of caring for a child with a recent concussion, the priority assessment is to assess for signs of increased intracranial pressure (ICP), making option A the correct answer. This is crucial because a concussion can lead to swelling or bleeding inside the brain, potentially causing increased ICP, which can be life-threatening if not promptly addressed. Option B, monitoring for difficulty swallowing, while important, is not the priority in this scenario as it is not directly related to the potential complications of a concussion such as increased ICP. Option C, assessing for skin integrity around the injury site, is also important but not as critical as monitoring for signs of increased ICP. Option D, evaluating the child's ability to perform tasks, is not the priority when assessing a child with a recent concussion as it does not directly address the immediate risks associated with increased ICP. Educationally, understanding the priority assessments in caring for a child with a concussion is essential knowledge for nurses working in pediatric settings. Recognizing the signs and symptoms of increased ICP and understanding the urgency of addressing them promptly can help prevent serious consequences and improve patient outcomes.

Correct Answer: A

Rationale: In caring for a child receiving total parenteral nutrition (TPN), it is crucial for the nurse to prioritize monitoring the child's blood glucose levels. This is because TPN is a high concentration of glucose and can lead to hyperglycemia if not properly monitored. Hyperglycemia can result in serious complications such as electrolyte imbalances, dehydration, and potential harm to vital organs. By closely monitoring blood glucose levels, the nurse can intervene promptly if any abnormalities are detected, thus ensuring the child's safety and well-being. Monitoring the child's blood pressure (option B) is important in general patient care; however, in the context of a child receiving TPN, monitoring blood glucose levels takes precedence due to the potential risks associated with hyperglycemia. Providing supplemental vitamin K (option C) is essential for patients on long-term TPN to prevent deficiencies; however, it is not the priority in this situation where immediate monitoring of blood glucose is crucial. Encouraging oral intake as soon as possible (option D) is not appropriate for a child receiving TPN as the primary source of nutrition is intravenous. Introducing oral intake prematurely can lead to complications and is not recommended until the healthcare team determines it is safe to do so. In an educational context, understanding the priority interventions in caring for a child on TPN is vital for nurses working in pediatric settings. This knowledge ensures safe and effective care delivery, promoting positive patient outcomes and minimizing potential complications.

Correct Answer: C

Rationale: In caring for a pediatric patient suspected of having chickenpox (varicella), the correct precaution required is airborne with isolation room (Option C). This is because chickenpox is primarily transmitted through airborne particles when an infected person coughs or sneezes. Airborne precautions are necessary to prevent the spread of the virus to others. Standard precautions (Option A) are important in infection control but may not be sufficient for diseases like chickenpox that are spread through airborne routes. Contact precautions (Option B) are used for diseases spread by direct contact with the patient or their environment, which is not the primary mode of transmission for chickenpox. Droplet precautions (Option D) are used for diseases transmitted through respiratory droplets, but chickenpox is primarily spread through airborne particles. In an educational context, understanding the appropriate precautions for different infectious diseases is crucial for nurses to provide safe and effective care. Teaching students about the rationale behind each type of precaution helps them make informed decisions in clinical practice, ensuring the safety of both patients and healthcare providers.

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Embryonal. Tracheal stenosis is a congenital condition where there is a narrowing of the trachea that can lead to respiratory distress in newborns. This problem develops during the embryonal period of lung development, which occurs around weeks 3-7 of gestation. During this stage, the trachea and major bronchi are formed from the foregut and undergo critical development. Option B) Saccular refers to the stage around weeks 24-36 of gestation where saccules form, which will later develop into alveoli. Option C) Canalicular is the stage around weeks 16-24 where the bronchioles divide into smaller bronchioles. Option D) Alveolar is the final stage of lung development which occurs from week 36 to adolescence, where alveoli continue to develop and mature. Understanding the timing of lung development stages is crucial for healthcare providers, especially in pediatric nursing, as it helps in recognizing when certain respiratory conditions may have originated. Recognizing tracheal stenosis as an embryonal issue informs the appropriate interventions and treatments needed to manage respiratory distress in newborns.

Correct Answer: B

Rationale: The correct answer is B) Day 22. The fetal heartbeat can typically be detected around the 5th week of pregnancy, which is approximately day 22. This is due to the development of the baby's heart starting around day 21, with the heartbeat becoming strong enough to be heard on an ultrasound around day 22. Option A) Day 8 is too early for the fetal heartbeat to be detected as the heart has not yet developed at this point. Option C) Day 45 is past the typical timeframe for detecting the fetal heartbeat, as it is usually detectable before this time. Option D) Day 60 is also beyond the expected timeframe for detecting the fetal heartbeat, as it should be visible on ultrasound before this point. In an educational context, understanding the timeline of fetal development and when key milestones like the detection of the fetal heartbeat occur is crucial for healthcare providers, especially those working in prenatal care. This knowledge helps in providing accurate information to pregnant women and ensuring appropriate monitoring and care throughout the pregnancy.