latex allergy is suspected in a child with spina bifida what are appropriate nursing interventions to include in care of this patient

ATI RN

Nursing Care of Children ATI

1. Latex allergy is suspected in a child with spina bifida. What are appropriate nursing interventions to include in care of this patient?

A. Avoid using any latex product.
B. Use only non-allergenic latex products.
C. Teach the family about long-term management of asthma.
D. Administer medication for long-term desensitization.

Correct answer: A

Rationale: The correct answer is A: 'Avoid using any latex product.' In the case of a suspected latex allergy, it is crucial to prevent exposure to latex products to avoid allergic reactions. Choice B is incorrect because there are no truly non-allergenic latex products. Choice C is irrelevant to the situation described in the question, as the child does not have asthma. Choice D is also incorrect because desensitization is not an immediate option for managing a suspected latex allergy.

2. The nurse is caring for a child who had a tonsillectomy. Which clinical manifestation should the nurse observe the child for in the postoperative period?

A. Arrhythmias
B. Increased swallowing
C. Increased blood sugar
D. Increased urinary output

Correct answer: B

Rationale: Correct Answer: B. Increased swallowing can indicate bleeding at the surgical site, which is a potential complication after tonsillectomy. Choice A, Arrhythmias, are not typically associated with tonsillectomy. Choice C, Increased blood sugar, is not a common clinical manifestation after a tonsillectomy. Choice D, Increased urinary output, is not a typical clinical manifestation to observe for in the postoperative period after a tonsillectomy.

3. Which congenital heart defect causes a "boot-shaped" heart on a chest x-ray?

A. Tetralogy of Fallot
B. Coarctation of the aorta
C. Transposition of the great arteries
D. Ventricular septal defect

Correct answer: A

Rationale: The correct answer is A: Tetralogy of Fallot. Tetralogy of Fallot, a congenital heart defect with four distinct abnormalities, often presents with a "boot-shaped" heart on chest x-ray due to right ventricular hypertrophy. This characteristic finding is due to the specific combination of defects in this condition. Coarctation of the aorta (choice B), Transposition of the great arteries (choice C), and Ventricular septal defect (choice D) do not typically result in a "boot-shaped" heart on a chest x-ray like Tetralogy of Fallot does.

4. When the nurse interviews an adolescent, which is especially important?

A. Focus the discussion on the peer group
B. Allow an opportunity to express feelings
C. Use the same type of language as the adolescent
D. Emphasize that confidentiality will always be maintained

Correct answer: B

Rationale: Allowing adolescents to express their feelings helps them feel heard and supported, which is crucial for effective communication.

5. When teaching a mother how to administer eye drops, where should the nurse tell her to place them?

A. At the lacrimal duct
B. On the sclera while the child looks to the outside
C. In the conjunctival sac when the lower eyelid is pulled down
D. Carefully under the eyelid while it is gently pulled upward

Correct answer: C

Rationale: Eye drops should be placed in the conjunctival sac, which allows the medication to be absorbed properly without causing irritation. Placing drops directly on the sclera or near the lacrimal duct is less effective and can cause discomfort.