what is an essential nursing action when caring for a young child with severe diarrhea
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Pediatric HESI Test Bank

1. What is an essential nursing action when caring for a young child with severe diarrhea?

Correct answer: D

Rationale: Promoting perianal skin integrity is crucial when caring for a young child with severe diarrhea as it helps prevent skin breakdown from the irritation caused by frequent stooling. Maintaining the IV (Choice A) may be necessary but is not directly related to managing perianal skin integrity. Taking daily weights (Choice B) is important for monitoring fluid status but not the priority when addressing perianal skin integrity. While replacing lost calories (Choice C) is essential, promoting perianal skin integrity takes precedence in preventing complications associated with skin breakdown.

2. When counseling a couple who suspect they could have a child with a genetic abnormality, what would be most important for the nurse to incorporate into the plan of care when working with this family?

Correct answer: D

Rationale: When counseling a couple about the possibility of having a child with a genetic abnormality, it is vital for the nurse to present information in a nondirective manner. This approach empowers the couple to make decisions based on their values and preferences, respecting their autonomy. Gathering information from three generations (Choice A) may not be necessary and might overwhelm the couple with unnecessary data. Informing the family about the need for a wide range of information (Choice B) is not as critical as supporting their decision-making process through a nondirective approach. While maintaining confidentiality (Choice C) is crucial, it is not the most important aspect compared to ensuring the couple can make informed choices that align with their beliefs and wishes.

3. A newborn is diagnosed with metatarsus adductus. The parents ask the nurse how this occurred. Which response by the nurse would be most appropriate?

Correct answer: B

Rationale: Metatarsus adductus is a condition characterized by the inward turning of the front part of the foot. It is often caused by the baby's position in the womb, leading to the foot adopting this position. Choice A is incorrect because metatarsus adductus is primarily related to positioning in utero rather than a genetic defect. Choice C is incorrect as there is an understanding of the common cause of this condition. Choice D is incorrect because metatarsus adductus specifically refers to a foot deformity, not a hip deformity.

4. The nurse is planning a discussion group for parents with children who have cancer. How would the nurse describe a difference between cancer in children and adults?

Correct answer: A

Rationale: The correct answer is A. Most childhood cancers, such as leukemias and sarcomas, affect tissues rather than specific organs, unlike many adult cancers. Choice B is incorrect because childhood cancers can be localized or spread, similar to adult cancers. Choice C is incorrect because childhood cancers can be highly responsive to treatment, especially when diagnosed early. Choice D is incorrect because the majority of childhood cancers cannot be prevented as they are often due to genetic mutations or unknown causes.

5. During a nap, a 3-year-old hospitalized child wets the bed. How should the nurse respond?

Correct answer: C

Rationale: When a 3-year-old hospitalized child wets the bed during a nap, the nurse should respond by changing the child's clothes without discussing the incident. This approach helps to maintain the child's dignity, avoid embarrassment, and reduce anxiety about bedwetting. Asking the child to help remake the bed (Choice A) may not be developmentally appropriate for a 3-year-old and could potentially lead to further distress. Putting clean sheets on the bed over a rubber sheet (Choice B) addresses the aftermath but does not directly address the child's needs and feelings. Explaining that children should call the nurse when they need to go to the bathroom (Choice D) may not be effective in this situation as the child may not have control over bedwetting during sleep.

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