An 8-year-old child diagnosed with meningitis is to undergo a lumbar puncture. What should the nurse explain is the purpose of this procedure?

Correct Answer: B

Rationale: A lumbar puncture is performed to obtain a sample of cerebrospinal fluid for analysis. This fluid is then examined for signs of infection, bleeding, or other abnormalities. Measuring the pressure of cerebrospinal fluid is typically done during the procedure itself, but it is not the primary purpose of the lumbar puncture. While a lumbar puncture can indirectly help relieve intracranial pressure by removing excess cerebrospinal fluid, this is not its primary purpose. Assessing the presence of infection in the spinal fluid is part of the analysis that follows the collection of the sample, making it a secondary outcome of the procedure.

Correct Answer: A

Rationale: In a newborn, a heart rate below 100 beats/min indicates the need for positive pressure ventilation to improve oxygenation. Providing blow-by oxygen or assessing skin condition/color may not address the primary issue of inadequate oxygenation due to the low heart rate. Starting chest compressions and contacting medical control is not warranted as the newborn is breathing spontaneously and only has a slightly low heart rate, which can be managed initially with positive pressure ventilations.

Correct Answer: B

Rationale: In atopic dermatitis, the nurse would expect to observe a dry, red, scaly rash with lichenification. Lichenification is thickened skin due to chronic scratching. Choices A, C, and D are incorrect. Erythematous papulovesicular rash is more characteristic of contact dermatitis, pustular vesicles with honey-colored exudates are seen in impetigo, and hypopigmented oval scaly lesions are typical of pityriasis alba.

Correct Answer: C

Rationale: Low-set ears with lobe creases are often associated with genetic disorders, such as Down syndrome, and can indicate underlying chromosomal abnormalities. This physical characteristic is a common feature seen in various genetic syndromes. The other choices, including feeding problems, weight and height measurements, and motor skills, are not typically specific indicators of genetic disorders in the absence of other associated features.

Correct Answer: C

Rationale: When a dysrhythmia is suspected, it is important for nurses to count the apical pulse for a full minute and compare it with the radial pulse rate. This method helps in identifying dysrhythmias because discrepancies between the apical and radial pulse rates can indicate irregular heart rhythms. Option A is incorrect because ordering an immediate electrocardiogram may not always be feasible or necessary as a first step. Option B, counting the radial pulse multiple times, is less accurate than comparing the apical and radial pulse rates. Option D involves an unnecessary step of having another person take simultaneous pulses when the nurse can do it effectively alone.

Correct Answer: A

Rationale: The most important nursing intervention for a child with leukemia receiving chemotherapy is to monitor for signs of infection. Chemotherapy suppresses the immune system, putting the child at a higher risk of developing infections. Early detection and prompt treatment of infections are crucial to prevent complications and improve outcomes. Monitoring for signs of bleeding (choice B), dehydration (choice C), and pain (choice D) are also important aspects of care, but in this scenario, the priority is to prevent and manage infections due to the compromised immune system.

Correct Answer: C

Rationale: The correct answer is C: Full-thickness burns involve the destruction of all layers of skin, extending into the subcutaneous tissue. This type of burn causes severe damage and loss of sensation due to nerve destruction. Choice A, erythema and pain, describes superficial burns (first-degree). Choice B, skin showing erythema followed by blister formation, describes partial-thickness burns (second-degree). Choice D, destruction injury involving underlying structures such as muscle, fascia, and bone, goes beyond the description of full-thickness burns.

Correct Answer: A

Rationale: The correct answer is administering pancreatic enzymes. In cystic fibrosis, there is a deficiency in pancreatic enzymes, leading to poor digestion and malabsorption of nutrients. Administering pancreatic enzymes is essential to ensure proper digestion and absorption of nutrients. Providing respiratory therapy and nutritional support are important aspects of care for a child with cystic fibrosis, but addressing the pancreatic enzyme deficiency takes priority in this scenario. Encouraging physical activity is beneficial for overall health but is not the priority intervention in this case.

Correct Answer: B

Rationale: The correct answer is B. While special dietary needs may be important for a child with Down syndrome, they are typically not the primary concern for a 1-month-old. The nurse would be least likely to focus on this aspect as immediate issues such as monitoring for congenital heart defects (echocardiogram), cervical spine abnormalities (radiographs), and respiratory infections are more critical in the early months. Adhering to dietary needs is important, but it is usually addressed as the child grows older and is not the priority during the infant stage.