Pediatric HESI

Correct Answer: C

Rationale: In a child with nephrotic syndrome, fluid volume excess is a priority nursing diagnosis due to the risk of edema and related complications. This patient may experience significant fluid retention, leading to edema, hypertension, and potential respiratory distress. Monitoring and managing fluid volume excess are crucial in preventing further complications and supporting the child's health during nephrotic syndrome.

Correct Answer: C

Rationale: The nurse's priority is to first reassure the mother that she is using albuterol correctly to open her son's airways during episodes of difficulty breathing. This reassurance helps build trust and ensures that the child receives the intended benefit of the medication. Once the mother feels confident in her administration technique, the nurse can then provide further education or address any concerns about the child's asthma management.

Correct Answer: A

Rationale: Duchenne muscular dystrophy is an X-linked recessive disorder caused by mutations in the DMD gene on the X chromosome. This disorder primarily affects males because they have one X chromosome, inherited from their mothers, who may be carriers of the mutated gene. Females have two X chromosomes, providing a protective effect as the normal gene on one X chromosome can compensate for the mutated gene on the other. Therefore, the nurse should explain to the parents that Duchenne muscular dystrophy is an inherited X-linked recessive disorder, which is why their son has the disease and why there is a risk of passing it on to future sons.

Correct Answer: D

Rationale: Administering factor VIII as prescribed is the priority intervention for a child with hemophilia experiencing joint pain and swelling. Factor VIII replacement therapy is crucial in managing bleeding episodes and preventing further damage to the affected joint in individuals with hemophilia.

Correct Answer: D

Rationale: For a lumbar puncture in a school-age child, EMLA cream should be applied 2.5 hours before the procedure. EMLA is commonly used to numb the skin, reducing pain and discomfort for the child during the procedure.