Which client requires immediate intervention by the RN?

A. A child with cystic fibrosis who is constipated.

B. A toddler with chicken pox who is scratching,

C. A child with acute renal failure and hyperkalemia.

D. An adolescent with a migraine and photophobia.

A 7 year old male is referred to the school clinic because he fainted on the playground. His

height is 3 feet, 7 inches (107.5 cm), he weighs 55 pounds (25 kilograms), and his body mass

index (BMI) is 20.9. Which assessment finding is most important for the RN to address?

A. He consumed2 bottles of water in 30 minutes prior to fainting.

B. Since age 3 he has experienced exercise induced asthma.

C. Reports drinking 3-4 high calorie, carbonated beverages daily.

D. The child’s father has a history of fainting when exercising.

The RN of a 6 year old girl is concerned about her child’s obesity. The child’s weight plots at the

75th percentile, and height at the 25th percentile. The child’s body mass index (BMI) is at the 85th

percentile for age and gender. Which interventions should the RN implement? (Select All That

Apply)

A. Explain that the child is likely to grow into her weight.

B. Determine the child’s usual physical activity pattern.

C. Obtain the child’s 3- day diet history based on the mothers input.

D. Inquire as to whether or not the school has a physical education program.

E. Tell the mother that girls hit their growth spurt before boys so eating more is expected.

(B, C, and D) are correct. The child’s growth parameters, particularly her BMI, indicate that she

is overweight. (B and D) assess for the child’s level of activity, which should be evaluated and

increased if possible. (C) Provides information about the quantity and quality of the child’s

dietary intake, which is information that is needed to create an individualized diet teaching plan.

(A) Does not consider the serious health and psychological consequences associated with

childhood obesity. Girls do not hit their growth spurt before boys in preadolescence, but this

child is only 6 years of age and the child’s obesity should not be negated because of this growth

and development expectation. (e)

A toddler with hemophilia is being discharged from the hospital. Which teaching should the RN

include in the discharge instructions to the mother?

A. Apply padding on the sharp corners of the furniture.

B. Prevent the client from running inside the house.

C. Give an 81 mg tablet of aspirin for pain relief.

D. Use a soft bristle toothbrush from frequent cleaning.