Janae has a seizure disorder; which of the following would be the lowest priority when caring for her? Observing and taking down data on all seizures

Correct Answer: C

Rationale: When caring for someone with a seizure disorder like Janae, the highest priority is ensuring their immediate safety and protection from injury during a seizure. This includes preventing falls, removing nearby hazards, and providing support during and after the seizure. Assessing for signs and symptoms of increased intracranial pressure is also important as it may indicate a serious complication requiring prompt medical attention. On the other hand, educating the family about anticonvulsant therapy, while important for long-term management, is considered a lower priority compared to the immediate safety and medical assessment needs of Janae during a seizure episode.

Correct Answer: B

Rationale: In the context of a pediatric patient diagnosed with gastroesophageal reflux (GER), the inappropriate nursing diagnosis among the options provided is B) Impaired oral mucous membrane. This is because GER primarily involves the reflux of gastric contents into the esophagus and potentially the mouth, rather than directly affecting the oral mucous membranes. A) Risk for aspiration is a relevant nursing diagnosis for a patient with GER, as the refluxed gastric contents can potentially be aspirated into the lungs, leading to respiratory complications. C) Deficient fluid volume is also a pertinent nursing diagnosis due to the potential for frequent regurgitation and vomiting in patients with GER, which can lead to dehydration and electrolyte imbalances. D) Imbalanced nutrition: Less than body requirements is another appropriate nursing diagnosis because GER can lead to feeding difficulties, poor weight gain, and inadequate nutrient intake in pediatric patients. Educationally, understanding the rationale behind selecting the correct nursing diagnosis in a specific clinical scenario like GER helps nurses provide targeted and effective care to pediatric patients. By analyzing each option critically, nurses can develop clinical reasoning skills and make informed decisions to optimize patient outcomes.

Correct Answer: B

Rationale: Sibling of Baby Angie who died of SIDS is the least probable to develop sudden infant death syndrome (SIDS) among the given choices. This is because siblings of infants who have died of SIDS are at a higher risk themselves due to potential genetic or environmental factors. Research suggests that siblings of infants who died of SIDS are at an increased risk compared to the general population, indicating a possible genetic predisposition or shared environmental influences. It is crucial for parents and caregivers of these siblings to take extra precautions and follow safe sleep practices to reduce the risk of SIDS.

Correct Answer: D

Rationale: Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by a low platelet count, leading to an increased risk of bleeding and easy bruising. Platelets are responsible for blood clotting and when their count is low, it can result in purpura (bruising) due to small blood vessels leaking blood into the skin. For this reason, the most common finding in ITP is bruising rather than blood clots, pallor, or dry membranes.

Correct Answer: B

Rationale: Transposition of the great vessels is a cyanotic congenital heart defect where the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. This results in two separate circulatory systems - one for oxygenated blood and another for deoxygenated blood. Due to this abnormal circulation, babies with transposition of the great vessels may present with severe cyanosis soon after birth. They can also develop tachypnea and tachycardia as compensatory mechanisms to maintain oxygen delivery. A STAT echocardiogram would confirm the diagnosis by showing the abnormal connection of the great vessels.