NURSING 1010 Assessment- Rationales RN VATI Nursing Care of Children 2016 UPDATED
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NURSING 1010
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NURSING 1010
Assessment- Rationales RN VATI Nursing Care of Children 2016
2. "Your child will be exposed to a moderate amount of radiation during the procedure." MY ANSWER
An MRI produces radiofrequency emissions from nonradioactive elements; therefore, there is no exposure to radiation involved during ...
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Assessment- Rationales RN VATI Nursing Care of Children 2016.
Assessment- Rationales RN VATI Nursing Care of Children
2016
2. "Your child will be exposed to a moderate amount of radiation during the
procedure." MY ANSWER
An MRI produces radiofrequency emissions from nonradioactive elements; therefore, there is no
exposure to radiation involved during this procedure.
"Your child might experience pain during the procedure."
An MRI does not cause pain, as it is a noninvasive procedure that emits radiofrequencies to
produce an image.
"This is considered an invasive procedure."
An MRI is a noninvasive procedure, unless an IV is prescribed when contrast is used. No
contrast is indicated for this child, so no IV is needed.
"You can remain in the room with your child during the procedure."
The parent may remain in the room with the child to provide comfort and reassurance during
the procedure.
3. Nausea
The nurse should identify that nausea is an early sign of increased intracranial pressure in a child.
Papilledema
The nurse should identify that papilledema is a late sign of increased intracranial pressure in a
child.
Dilated pupils
The nurse should identify that dilated pupils along with a decreased pupillary response are late
signs of increased intracranial pressure in a child.
Bradycardia
MY ANSWER
The nurse should identify that bradycardia is a late sign of increased intracranial pressure in a
child.
4. Initiate contact precautions.
The nurse should initiate contact, droplet, and standard precautions for RSV because exposure to
contaminated secretions can transmit the virus. RSV can live on objects for several hours and on
hands for 30 min.
Perform chest percussion and postural drainage.
The nurse should perform periodic suctioning of the nose or nasopharynx to clear nasal
secretions. Chest percussion and postural drainage are not routinely recommended for an infant
who has RSV.
Encourage clear liquids by
mouth. MY ANSWER
The nurse should not encourage clear liquids by mouth, because the infant has tachypnea. Oral
fluids are contraindicated in the presence of tachypnea due to the risk for aspiration.
Administer IV antibiotics.
The nurse should not plan to administer IV antibiotics, because RSV is a viral infection.
Antibiotics may be prescribed if a secondary bacterial infection occurs.
,Assessment- Rationales RN VATI Nursing Care of Children 2016.
5. Warm extremities
Heart failure involves an inability of the heart to pump effectively, limiting perfusion to major
organs and the extremities. The nurse should expect a child who has heart failure to exhibit
pale, cool extremities.
Frequent headaches
The child who has heart failure can exhibit neurologic manifestations, such as increased
restlessness or irritability as a result of hypoxia and impaired cardiac function; however, frequent
headaches are not an expected manifestation associated with heart failure.
Distended neck veins
The child who has heart failure will exhibit manifestations of increased blood volume, such as
distended neck veins. This occurs because the hormone ADH is excreted, which holds onto
sodium and water in response to decreased cardiac output and renal perfusion.
Weight loss
MY ANSWER
The child who has heart failure will exhibit weight gain as a result of sodium and water retention.
As the heart failure progresses, dependent and periorbital edema, ascites, and pulmonary
effusions result.
6. The infant falls to a sitting position while learning how to walk.
The infant falling to a sitting position while learning how to walk is not a manifestation of
hemophilia, as this is an expected part of growth and development.
The infant bleeds slightly when scratched by a cat.
Bleeding slightly when a minor scratch occurs is not a manifestation of hemophilia; however, if
the bleeding is not easily controlled, the parent should notify the provider.
The infant's skinned knee drains serosanguineous fluid.
MY ANSWER
The drainage of serosanguineous fluid from a skinned knee is not a manifestation of
hemophilia. This is an expected finding after a skin injury and does not warrant evaluation.
The infant's knees are reddened and edematous.
The nurse should identify that the infant might be experiencing hemarthrosis if redness, edema,
and warmth of the joints are noted. Bleeding into the joints is the most frequent form of
internal bleeding in children who have hemophilia.
"I should eat extra food on busy days when I am more active" is correct. The nurse should
instruct the child to increase her intake of allowable foods when she is more active. Exercise
lowers blood glucose levels during and after activity. Food intake should be adjusted to
compensate for the release of insulin into the circulatory system and prevent episodes of
hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate
play or activity.
"I should wait 2 hours after eating before playing with my friends" is incorrect. The child should
play or exercise within 2 hr of eating because exercise requires her to have more carbohydrates
in her system. Waiting 2 hr after eating before play or exercise increases the likelihood of a
hypoglycemic episode. A carbohydrate snack will most likely be needed during prolonged play or
, Assessment- Rationales RN VATI Nursing Care of Children 2016.
exercise and another a few hours after the activity.
"I should increase my intake of sugar-free fluids when I am sick" is correct. The nurse should
instruct the child to increase her intake of sugar-free fluids when she is sick. Fluids flush out
ketones to prevent dehydration. The nurse should recommend sugar-free liquids, such as water,
broth, and tea to the child. The child should continue with her usual intake at mealtimes and
follow her recommended meal plan as much as possible.
"I should eat a snack 30 minutes before my baseball game starts" is correct. The nurse should
instruct the child to eat a recommended snack 30 min prior to a planned activity, such as a
baseball game. If the game is prolonged, she should have a snack every 45 min to an hour. If for
some reason the child cannot tolerate the extra food, the next intervention is to decrease the
child's insulin dose before baseball games.
"I should have a 16 ounce sports drink if I start feeling weak or shaky" is incorrect. The child
should consume 8 oz of a sports drink if she feels hypoglycemic, rather than 16 oz. Clinical
manifestations of hypoglycemia include dizziness, headache, irritability, weakness, shakiness,
and confusion. An 8-oz sports drink contains 15 g of carbohydrate. If the child consumes 16 oz, it
would contain a minimum of 30 g of carbohydrate and most likely cause the child to become
hyperglycemic and require a dose of insulin.
8. "Your child's skin will appear
flushed." MY ANSWER
The nurse should inform the parents that their child will have pale skin near the end of his life.
The skin is cool to the touch and might appear grayish-blue as death nears. Mottling might
occur in the extremities and move toward the body core because of a decrease in cardiac
output and perfusion to the extremities.
"Your child will lose movement in his legs."
The nurse should inform the parents that their child will lose movement of the lower
extremities. This progressive loss of movement will move up the body as death nears.
"Your child will first lose his ability to hear."
The nurse should inform the parents that the sense of hearing is the last sense to fail as death
nears. Loss of sensation develops before hearing loss, and the child might become more
sensitive to light.
"Your child's blood pressure will start to increase."
The nurse should inform the parents that their child will experience decreased cardiac output,
leading to a drop in blood pressure and decreased pulses.
Koplik spots
The nurse should not expect a child who has viral meningitis to have Koplik spots. Koplik spots
are small red spots with a white center that are found on the oral mucosa in children who have
measles.
Decreased protein in the cerebrospinal fluid
The nurse should expect a child who has viral meningitis to exhibit either a normal or slightly
elevated protein level in the cerebrospinal fluid due to increased permeability of the blood-brain
barrier.
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