the nurse closely monitors the temperature of a child with minimal change nephrotic syndrome the purpose of this assessment is to detect an early sign
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Nursing Elites

HESI LPN

Pediatric HESI 2024

1. The healthcare provider closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?

Correct answer: A

Rationale: Monitoring the temperature of a child with minimal change nephrotic syndrome is crucial for detecting early signs of infection, a common complication in this condition. In nephrotic syndrome, the child's immune system is compromised, making them more susceptible to infections. Monitoring for fever or any changes in temperature can help healthcare providers intervene promptly to prevent further complications. Hypertension (choice B) is not typically associated with minimal change nephrotic syndrome. Encephalopathy (choice C) refers to brain dysfunction and is not a common complication of nephrotic syndrome. Edema (choice D) is a primary manifestation of nephrotic syndrome but is not typically monitored through temperature assessment.

2. The nurse is caring for a 1-month-old girl with low-set ears and severe hypotonia who was diagnosed with trisomy 18. Which nursing diagnosis would the nurse identify as most likely?

Correct answer: C

Rationale: The correct nursing diagnosis would be 'Grieving related to the child's poor prognosis.' Trisomy 18 is associated with a poor prognosis, and families often experience feelings of grief and loss when dealing with such a diagnosis. The choice 'Interrupted family process' does not directly address the emotional response to the prognosis. 'Deficient knowledge' may be a concern but does not address the emotional aspect of dealing with a poor prognosis. 'Ineffective coping related to stress from providing care' focuses more on the caregiver's ability to cope rather than the family's response to the child's condition.

3. Parents of a sick infant talk with a nurse about their baby. One parent says, “I am so upset; I didn’t realize our baby was ill.” What major indication of illness in an infant should the nurse explain to the parent?

Correct answer: C

Rationale: The correct answer is C. Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it can indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, not just an indication of illness. Excessive perspiration (choice B) can occur due to various reasons and is not a specific major indication of illness. Crying immediately after feedings (choice D) is a common behavior in infants and not necessarily a major indication of illness.

4. A parent calls the clinic because their child has ingested a small amount of household bleach. What should the nurse advise?

Correct answer: C

Rationale: The correct answer is to advise the parent to call the poison control center. When a child ingests household bleach, it is important to seek guidance from professionals who can provide specific and immediate advice on managing the situation. Administering activated charcoal (Choice A) is not recommended for household bleach ingestion. Inducing vomiting immediately (Choice B) can lead to further complications and is not the recommended first response. Taking the child to the emergency department (Choice D) should be done based on the advice received from the poison control center.

5. What should be included in the nursing plan of care for a 6-month-old infant admitted to the pediatric unit with a diagnosis of respiratory syncytial virus (RSV)?

Correct answer: C

Rationale: The correct answer is C: Maintain standard and contact precautions. RSV is highly contagious, primarily spread through respiratory secretions. Therefore, it is crucial to implement infection control measures such as standard and contact precautions to prevent the spread of the virus to other patients, staff, and visitors. Choice A is incorrect because warmth and dryness are not specific interventions for RSV; the focus should be on infection control. Choice B may increase the risk of exposing others to RSV, so limiting visitors is recommended. Choice D is unnecessary because RSV is a viral infection, and antibiotics are not effective against viruses.

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