the nurse is caring for a 10 year old with duchenne muscular dystrophy as part of the plan of care the nurse focuses on maintaining his cardiopulmonar
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Pediatric HESI Test Bank

1. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion?

Correct answer: B

Rationale: Upright positioning is the optimal intervention to promote maximum chest expansion in a child with Duchenne muscular dystrophy. By placing the child in an upright position, gravity can assist in expanding the chest cavity, facilitating better lung expansion and improving breathing efficiency. Deep-breathing exercises may be beneficial but are not as effective in maximizing chest expansion as upright positioning. Coughing and chest percussion focus more on airway clearance and are not directly aimed at promoting chest expansion.

2. A nurse is caring for a 7-year-old child with a diagnosis of type 1 diabetes mellitus. What is the priority nursing intervention?

Correct answer: B

Rationale: The priority nursing intervention for a 7-year-old child with type 1 diabetes mellitus is to monitor blood glucose levels. This is crucial for managing and adjusting insulin therapy effectively. Administering insulin as prescribed is important, but monitoring blood glucose levels takes precedence as it guides insulin administration. Teaching the child how to self-administer insulin and encouraging regular exercise are also important aspects of diabetes management, but they are not the priority in this situation.

3. What complication of mumps is crucial for adolescents to prevent?

Correct answer: A

Rationale: The correct answer is A, Sterility. Mumps can lead to sterility, particularly in adolescent males, highlighting the significance of vaccination to prevent this serious complication. While hypopituitarism (choice B) can be a potential complication of mumps, it is not as crucial to prevent in adolescents compared to the risk of sterility. Choices C and D, Decreased libido and Decreased androgens, are not direct complications of mumps and are not the primary concerns for adolescents in relation to mumps prevention.

4. A nurse is planning an initial home care visit to a mother who gave birth to a high-risk infant. For what time of day should the nurse schedule the visit for it to be most productive?

Correct answer: C

Rationale: Scheduling the visit at a time that is convenient for the family is the most appropriate choice. This ensures that the family is receptive and available, making the visit more productive. Choice A is incorrect because the presence of the husband may be important for support and decision-making. Choice B focuses solely on the mother and the infant's feeding time, which may not align with the family's overall availability. Choice D is incorrect as it emphasizes the nurse's convenience rather than the family's, which may not lead to an effective visit.

5. A child with a diagnosis of leukemia is admitted to the hospital with a fever. What is the priority nursing intervention?

Correct answer: D

Rationale: The priority nursing intervention for a child with leukemia admitted to the hospital with a fever is to monitor for signs of infection. Children with leukemia are immunocompromised, making them more susceptible to infections. Monitoring for signs of infection helps in early detection and timely intervention, which is crucial in preventing complications. Administering antibiotics (choice A) may be necessary if an infection is suspected or confirmed, but the priority is to assess for signs of infection first. Administering antipyretics (choice B) may help reduce fever, but it does not address the underlying cause, which could be an infection. Providing nutritional support (choice C) is important for overall health but is not the priority when a child with leukemia presents with a fever, as infection needs to be ruled out or managed first.

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