a 3 year old child with hirschsprung disease is hospitalized for surgery a temporary colostomy will be necessary how should the nurse prepare this chi
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Nursing Elites

ATI RN

RN Nursing Care of Children 2019 With NGN

1. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. How should the nurse prepare this child?

Correct answer: B

Rationale: Preparation is essential even for a young child, as they need to adjust to the temporary colostomy and understand the changes to their body, which can be confusing and distressing without proper explanation.

2. What laboratory finding, in conjunction with the presenting symptoms, indicates minimal change nephrotic syndrome?

Correct answer: D

Rationale: Reduced serum albumin is a hallmark of minimal change nephrotic syndrome (MCNS) due to massive proteinuria. This results in hypoalbuminemia, which contributes to the edema characteristic of this condition.

3. The nurse is planning to counsel family members as a group to assess the family's group dynamics. Which theoretical family model is the nurse using as a framework?

Correct answer: C

Rationale: Family systems theory views the family as an interconnected system where changes in one member affect the entire family, making it ideal for assessing group dynamics.

4. The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hours ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include?

Correct answer: C

Rationale: Leaving the gastrostomy tube open to gravity drainage prevents the accumulation of air and fluids, reducing the risk of complications such as vomiting or aspiration in the immediate postoperative period. Keeping the tube clamped or suctioning it can lead to pressure buildup, increasing the risk of complications. Securing the tube with tape is important but not the primary action related to the gastrostomy tube in this case.

5. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the “finger-to-nose test.” What is the purpose of this test?

Correct answer: B

Rationale: The finger-to-nose test assesses cerebellar function, which is responsible for balance and coordination. The test evaluates how well the cerebellum controls motor functions and coordination. Choice A, deep tendon reflexes, is incorrect because this test does not assess reflexes but rather cerebellar function. Choice C, sensory discrimination, is incorrect as this test focuses on motor function rather than sensory abilities. Choice D, ability to follow directions, is incorrect since the test primarily assesses motor coordination and not cognitive skills related to following instructions.

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