when assessing the breath sounds of an 18 month old child who is crying what action should the nurse take
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Nursing Elites

HESI RN

Pediatric HESI

1. When assessing the breath sounds of an 18-month-old child who is crying, what action should the healthcare professional take?

Correct answer: C

Rationale: Allowing the child to play with a stethoscope can help distract them, making it easier to auscultate breath sounds. This approach can create a more cooperative and engaging environment for the child, facilitating a more accurate assessment of their breath sounds. Choice A is incorrect because it does not address the need for an assessment. Choice B is not ideal as it puts pressure on the caregiver and may not be effective in calming the child. Choice D is not the best option as it does not actively involve the child in the assessment process and may not provide an accurate representation of their breath sounds.

2. When assessing a 10-year-old newly diagnosed with osteomyelitis, which information is most important for the nurse to obtain?

Correct answer: A

Rationale: In a 10-year-old with newly diagnosed osteomyelitis, the most important information for the nurse to obtain is the recent history of infection recurrences. This is crucial because osteomyelitis is an infection of the bone, and assessing for any recent recurrence of infections can help in determining the possible source of the osteomyelitis and guide the treatment plan accordingly. Choices B, C, and D are less relevant in the immediate assessment of a newly diagnosed case of osteomyelitis as they do not directly impact the current infection or treatment plan.

3. A 3-year-old child is brought to the clinic by the parents who are concerned that the child is not yet potty trained. What is the nurse’s best response?

Correct answer: B

Rationale: The correct answer is B because it is important to acknowledge that children develop at different rates. By offering support and discussing strategies for potty training, the nurse can provide the necessary guidance without causing unnecessary concern or pressure on the parents. Choice A is incorrect because it dismisses the parents' concerns. Choice C is incorrect because jumping to the conclusion of developmental delays without further assessment or discussion can cause undue anxiety. Choice D is incorrect because forcing a child to use the potty can lead to resistance and negative associations with potty training.

4. The parents of a 3-year-old boy who has Duchenne muscular dystrophy ask, 'How can our son have this disease? We are wondering if we should have any more children.' What information should the nurse provide to parents?

Correct answer: A

Rationale: The correct answer is A. Duchenne muscular dystrophy is an X-linked recessive disorder that primarily affects males. It is crucial for the nurse to explain to the parents that this condition follows an inheritance pattern where the gene mutation responsible for the disorder is located on the X chromosome. Males have only one X chromosome, so if they inherit the mutated gene, they will develop the disease. Females, on the other hand, have two X chromosomes, providing a backup copy that can compensate for the mutation. Understanding this inheritance pattern is essential for family planning decisions, as the risk of passing on the disorder to future children can be explained based on this genetic inheritance. Choices B, C, and D are incorrect because they do not address the genetic basis of Duchenne muscular dystrophy or its inheritance pattern, which is crucial information for the parents in this scenario.

5. The mother of a 14-year-old who had a below-the-knee amputation for osteosarcoma tells the nurse that her child is angry and blaming her for allowing the amputation to occur. Which response is best for the nurse to provide?

Correct answer: D

Rationale: Acknowledging the child's anger as a coping mechanism helps validate their feelings and can open a dialogue for further support.

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