Pediatrics HESI 2023

Correct Answer: C

Rationale: The correct instruction for the nurse to include in the teaching plan is to advise the child to soak the area in warm water every day. Soaking the area in warm water helps to gently remove dead skin without causing irritation, facilitating the safe and comfortable removal of the cast. Applying petroleum jelly (Choice A) may not be necessary and could interfere with the cast removal process. Rubbing the skin vigorously (Choice B) can lead to skin damage and should be avoided. Washing the skin with diluted peroxide and water (Choice D) is not recommended as peroxide can be irritating to the skin and may not aid in cast removal.

Correct Answer: B

Rationale: Seizures are a common complication in children with high fever and altered mental status, indicating a risk of febrile seizures. While vomiting can occur with altered mental status, seizures are of higher concern due to the association with febrile illnesses in children. Combativeness may be a concern in some altered mental status cases but is not as common as seizures. Respiratory distress, although important, is not the primary concern in this scenario given the symptoms presented.

Correct Answer: A

Rationale: Checking blood glucose levels before meals and at bedtime is essential for managing type 1 diabetes mellitus. This timing helps in assessing the effectiveness of insulin therapy, making adjustments to insulin doses, and preventing hyperglycemia and hypoglycemia. Option B is incorrect because it focuses on the method of obtaining blood samples rather than the timing of monitoring. Option C is incorrect as urine test strips are not recommended for accurate blood glucose monitoring in type 1 diabetes. Option D, recognizing signs of hypoglycemia, is important but not the primary emphasis when teaching about blood glucose monitoring.

Correct Answer: A

Rationale: The most important nursing intervention for a child with leukemia receiving chemotherapy is to monitor for signs of infection. Chemotherapy suppresses the immune system, putting the child at a higher risk of developing infections. Early detection and prompt treatment of infections are crucial to prevent complications and improve outcomes. Monitoring for signs of bleeding (choice B), dehydration (choice C), and pain (choice D) are also important aspects of care, but in this scenario, the priority is to prevent and manage infections due to the compromised immune system.

Correct Answer: C

Rationale: The correct answer is C: Full-thickness burns involve the destruction of all layers of skin, extending into the subcutaneous tissue. This type of burn causes severe damage and loss of sensation due to nerve destruction. Choice A, erythema and pain, describes superficial burns (first-degree). Choice B, skin showing erythema followed by blister formation, describes partial-thickness burns (second-degree). Choice D, destruction injury involving underlying structures such as muscle, fascia, and bone, goes beyond the description of full-thickness burns.