The nurse is preparing to feed a 10-month-old child diagnosed with failure to thrive (FTT). Which actions should the nurse plan to implement?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) All are correct. When caring for a 10-month-old child diagnosed with failure to thrive, it is crucial for the nurse to implement a comprehensive approach. Being persistent (Option A) is important because feeding difficulties can be common in children with FTT, and the nurse needs to persevere in trying different feeding strategies to ensure adequate nutrition intake. Introducing new foods slowly (Option B) is essential to monitor for any adverse reactions or sensitivities the child may have to certain foods. Maintaining a calm, even temperament (Option D) is crucial in creating a positive feeding environment as stress and anxiety can negatively impact a child's feeding behavior. The incorrect options can be ruled out as they do not address the comprehensive care required for a child with FTT. Educational context here emphasizes the importance of a holistic approach in caring for children with specific health conditions, ensuring their safety, comfort, and optimal health outcomes.

Correct Answer: B

Rationale: The most appropriate nursing action in this scenario is to direct the father to seek immediate medical treatment (Option B). Visine eye drops contain tetrahydrozoline, which when ingested can lead to serious consequences like decreased heart rate, decreased body temperature, respiratory depression, seizures, coma, and even death, especially in young children. Seeking medical treatment promptly is crucial to prevent these adverse effects and ensure proper management. Reassuring the father that Visine is harmless (Option A) is incorrect as it conveys a dangerous message that could lead to delayed treatment. Recommending inducing vomiting with ipecac (Option C) is not recommended due to the risks associated with ipecac use and the potential for aspiration. Advising to dilute Visine by giving the daughter several glasses of water (Option D) is also not appropriate as it does not address the potential serious effects of tetrahydrozoline ingestion. In an educational context, it is important for nurses to recognize the potential dangers of household items like eye drops and to provide accurate and timely information to parents and caregivers. This scenario highlights the importance of quick assessment and appropriate action in cases of potential poisoning, emphasizing the critical role nurses play in promoting patient safety and advocacy.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Edema of the lips, tongue, and pharynx. This clinical manifestation is most suggestive of ingestion of a corrosive product because corrosive substances can cause significant swelling and edema of the mucous membranes they come into contact with. This is a localized reaction that occurs due to the corrosive nature of the substance damaging the tissues. Option A) Tinnitus, and Option B) Disorientation are not typical clinical manifestations associated with ingestion of corrosive products. Tinnitus is a ringing in the ears and is not directly related to corrosive ingestion. Disorientation can be a symptom of poisoning, but it is not specific to corrosive substances. Option C) Stupor, lethargy, and coma are more commonly associated with central nervous system depressants or toxins affecting the brain rather than corrosive substances which primarily cause local tissue damage. In an educational context, understanding the specific clinical manifestations of different types of poisonings is crucial for nurses caring for children. Recognizing the signs of corrosive ingestion can prompt swift and appropriate intervention to prevent further damage and improve outcomes for the child. Nurses must be knowledgeable about the effects of various toxins to provide safe and effective care to pediatric patients.

Correct Answer: B

Rationale: In the context of acetaminophen poisoning, the correct clinical manifestation is hepatic involvement (Answer B). Acetaminophen toxicity primarily affects the liver, leading to hepatic necrosis and liver failure. This is a crucial clinical sign to recognize as prompt treatment is essential to prevent severe complications and potential death. Option A (Hyperpyrexia) is incorrect because acetaminophen poisoning typically does not cause high fever. Option C (Severe burning pain in stomach) is also incorrect as acetaminophen toxicity may cause abdominal pain but not specifically described as severe burning pain. Option D (Drooling and inability to clear secretions) is unrelated to acetaminophen poisoning and may be seen in other conditions affecting the respiratory and salivary systems. In an educational context, understanding the clinical manifestations of acetaminophen poisoning is vital for nurses caring for children. Recognizing these signs early can prompt timely interventions and prevent further harm. Nurses should also be aware of the importance of accurate medication dosing to prevent accidental acetaminophen toxicity in pediatric patients.

Correct Answer: B

Rationale: The correct answer is B) Mixing with a flavorful beverage in an opaque container with a straw. Activated charcoal is used to absorb toxins in cases of poisoning. Mixing it with a flavorful beverage helps mask the taste of charcoal, making it more palatable for the child to ingest. Using an opaque container prevents the child from seeing the black color of the charcoal, which may be off-putting. Offering a straw can also help the child drink the mixture more easily. Option A is incorrect because activated charcoal should be given all at once, not divided into two doses. Delaying administration could reduce its effectiveness in absorbing the aspirin. Option C is incorrect because the sight of the black mixture may deter the child from drinking it, leading to potential non-compliance. Option D is incorrect because using a nasogastric tube should be a last resort and is not necessary in this case where the child is awake and alert and capable of drinking the charcoal mixture. In an educational context, it is important for nurses to understand the proper administration of medications and treatments in pediatric patients. By making the charcoal mixture more palatable and visually appealing, nurses can improve compliance and ensure the child receives the full therapeutic benefit of the treatment.