Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause:

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Cerebral edema. The rationale behind this is that fluid overload can lead to increased intracranial pressure, causing cerebral edema in patients with meningitis. Monitoring fluid intake in this case is crucial to prevent this potentially serious complication. Option B) Dehydration is incorrect because the patient is not at risk of dehydration due to receiving both IV and oral fluids. Option C) Heart failure is not directly related to fluid overload in this specific case of a healthy adolescent with meningitis. Option D) Hypovolemic shock is also not applicable as the patient is not currently experiencing hypovolemia. In an educational context, understanding the impact of fluid management in pediatric patients with specific conditions like meningitis is essential for nurses caring for these patients. This knowledge helps nurses prevent complications and provide optimal care to pediatric patients with cardiovascular disorders.

Correct Answer: A

Rationale: In this scenario, the highest priority nursing intervention for a 4-month-old with meningococcal meningitis is option A: Instituting droplet precautions. This is the correct choice because meningococcal meningitis is a highly contagious infection spread through respiratory droplets. By instituting droplet precautions, the nurse can help prevent the spread of the infection to other patients, visitors, and healthcare workers. This action is crucial in maintaining a safe environment and preventing further transmission of the disease. Option B, administering acetaminophen, though important for managing fever and discomfort, is not the highest priority in this case. Controlling the spread of the infection takes precedence over symptom management. Option C, obtaining history information from the parents, is also important for the overall care of the patient but is not the highest priority at the moment. Immediate actions to prevent the spread of infection are critical before delving into detailed history taking. Option D, orienting the parents to the pediatric unit, is not necessary as the priority lies in the immediate medical needs of the child and preventing the spread of the infection. Educationally, this question emphasizes the importance of prioritizing nursing interventions based on the patient's condition and the potential risks to others. Understanding the significance of infection control measures is vital for nurses caring for pediatric patients with contagious diseases to ensure the safety of everyone in the healthcare setting.

Correct Answer: C

Rationale: In pediatric nursing, it is crucial to understand the correct timing for evaluating different diagnostic tests to ensure accurate results. In the case of a tuberculosis intradermal skin test, the correct answer is option C) In 48 to 72 hours. This timeframe allows for the proper immune response to develop and manifest as a visible reaction if the individual has been infected with tuberculosis. Option A) Immediately is incorrect because immediate evaluation does not allow adequate time for the body's immune response to occur and may lead to a false negative result. Option B) Within 24 hours is also incorrect as this timeframe may still be too early to observe a reaction, potentially resulting in an inaccurate interpretation. Option D) After 5 days is incorrect because waiting this long may lead to excessive induration, making it challenging to accurately interpret the test results due to potential non-specific reactions. Educationally, understanding the timing of result evaluation for diagnostic tests like the tuberculosis skin test is essential for nurses caring for pediatric patients. This knowledge ensures accurate assessment and interpretation of results, leading to appropriate interventions and treatment plans based on reliable diagnostic information. By grasping these principles, nurses can provide optimal care and support for pediatric patients at risk for tuberculosis infection.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Worsening dyspnea. Excessive IV fluid intake can lead to fluid overload, causing pulmonary congestion and worsening dyspnea due to increased fluid in the lungs. Understanding the signs and symptoms of fluid overload is crucial in pediatric nursing as it can lead to serious complications. Option B) Gastric distension is incorrect because it is more indicative of gastrointestinal issues rather than excessive IV fluid intake. Option C) Nausea and vomiting are nonspecific symptoms and can be caused by various factors, not specifically related to excessive IV fluid intake. Option D) Temperature of 102°F (38.9°C) is more indicative of a fever or infection rather than excessive IV fluid intake. Educationally, it is important for nurses to closely monitor pediatric patients receiving IV fluids, especially at higher rates, to identify signs of fluid overload promptly. Understanding the signs and symptoms of fluid overload and differentiating them from other conditions is essential for providing safe and effective care to pediatric patients with cardiovascular disorders.

Correct Answer: A

Rationale: In a newborn infant suspected to have a ventricular septal defect (VSD), the assessment finding that would lead the nurse to suspect this condition is a loud, harsh murmur with a systolic thrill (Option A). This is because a VSD causes abnormal blood flow between the ventricles, resulting in turbulent blood flow and the characteristic murmur and thrill. Option B, cyanosis when crying, is more indicative of a cyanotic heart defect rather than a VSD. VSDs typically present with a systolic murmur rather than cyanosis. Option C, blood pressure higher in the arms than in the legs, is suggestive of coarctation of the aorta, a different cardiovascular disorder, not VSD. Option D, a machinery-like murmur, is associated with patent ductus arteriosus (PDA), not VSD. PDA murmur is continuous, unlike the systolic murmur heard in VSD. Educationally, understanding these assessment findings is crucial for pediatric nurses caring for infants with cardiovascular disorders. Recognizing specific murmurs and associated clinical manifestations aids in early identification, appropriate referral, and timely intervention, ultimately improving outcomes for infants with congenital heart defects.