Which health teaching concept should the nurse emphasize when instructing the parents of a child with polycythemia caused by a congenital heart disorder?
Encourage progressive activity.
Expect the skin to turn yellow.
Prepare for seizures.
Prevent dehydration.
The Correct Answer is D
Choice A rationale
Encouraging progressive activity is generally beneficial for children with various health conditions, but it is not the primary focus for a child with polycythemia caused by a congenital heart disorder. The main concern is managing the increased blood viscosity and preventing complications related to it.
Choice B rationale
Expecting the skin to turn yellow is not a typical symptom of polycythemia. Jaundice is more commonly associated with liver conditions or hemolytic diseases, not polycythemia caused by congenital heart disorders.
Choice C rationale
Preparing for seizures is not directly related to polycythemia. Seizures are more commonly associated with neurological conditions or severe electrolyte imbalances, not polycythemia.
Choice D rationale
Preventing dehydration is crucial for children with polycythemia because dehydration can increase blood viscosity, leading to a higher risk of thrombotic events. Ensuring adequate hydration helps maintain proper blood flow and reduces the risk of complications.
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Correct Answer is A
Explanation
Choice A rationale
The inability to stand upright without support at 15 months is a developmental delay that should be reported to the provider. By this age, most toddlers can stand and walk independently. Delays in motor skills can indicate underlying neurological or musculoskeletal issues.
Choice B rationale
Building a tower of six to seven cubes is a skill typically developed by 24 months. At 15 months, a toddler may only be able to stack two to three cubes.
Choice C rationale
Jumping with both feet is a skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to be able to jump with both feet.
Choice D rationale
Turning a doorknob is a fine motor skill that develops around 24 to 36 months. It is not expected for a 15-month-old toddler to have this skill.
Correct Answer is C
Explanation
Choice A rationale
Administering an inhaled glucocorticoid can help reduce inflammation in the airways, but it is not the priority intervention in an acute asthma exacerbation. The primary concern is to provide rapid bronchodilator.
Choice B rationale
Obtaining a peak flow reading can help assess the severity of the asthma exacerbation, but it is not the priority intervention. The primary concern is to provide rapid bronchodilator.
Choice C rationale
Administering a short-acting beta-agonist (SABA) is the priority intervention. SABAs, such as albuterol, provide rapid bronchodilation and relieve bronchospasm, which are the main features of status asthmatics.
Choice D rationale
Determining the cause of the acute exacerbation can help guide long-term management, but it is not the priority intervention in an acute asthma exacerbation. The primary concern is to provide rapid bronchodilation.