Pediatric Nursing Assessment: Critical Cases

Exc. 4 1.onAthe toddler girl, Assessment 5 years old, isresults: being treated inthethehospital, children'swant room, with a diagnosis of DHF fifth day. bored in to go home immediately. The nurse will do play therapy.What type of play is right for this child? A. Bekel ball B. Piggyback C. Panda doll D. Cooking utensils E. Pencil and drawing book Answer Key: C. Panda doll Discussion:When aanxiety toddlerand is admitted and treated in hospital, thisfamily. will cause physicalcare and psychological stress for both the toddler and his Atraumatic isexperienced therapeuticbycare that minimizes or eliminatesofpsychological andtophysical distress toddlers and their families.One the steps taken reduce and prevent the impact of separation of toddlers from their families is by giving parents the opportunity to accompany toddlersage whentoddlers. they are being cared for. Panda dolls are a type of therapeutic game forthepreschool 2.andA boy, 6 yearsofold, was Based admitted to theassessment children's room with complaints of cough,were fever shortness breath. on data and analysis, nursing problems found, namely ineffective airway clearance, nursing intervention was chest physiotherapy. When performing chest physiotherapy, the nurse performs percussion on the child's chest or back.How to carry out this action? A. Rhythmic beating technique with curved palms B. Do the beating with your palms wide open C. Perform vibrations using the palms of the hands D. Prop up the pillow before percussion E. Using special tool Answer Key: A. Rhythmic beating technique with curved palms Discussion:With the curved handdoes percussion technique, the location of percussed the blow iswith morean focused/precise and this action not cause the child pain like if we open palm.Rhythmic beating on the chest wall and back aims toforrelease mucus or the secretions that stick to the respiratory wall and make it easier them to flow into throat. This makes it easier for the child to expel mucus. 3.breath. A girl,Assessment 7 years old, results: was admitted to the children's roomfrequency with complaints of shortness ofto chest retraction, breathing 30x/minute, appears be usinginaccessory muscles for breathing. The nursing problem that was established was a change breathing pattern related to a decrease in lung expansion. The child received oxygen therapy withthea procedure? nasal cannula.What are the priority things that need to be considered during A. Make the child's sleeping position as comfortable as possible B. Maintain a quiet environment C. Pay attention to the humidifier bottle so that it is not empty D. Post an announcement on the room door "patient needs rest" E. Encourage parents to report immediately if oxygen runs out Answer Key: C. Make sure the humidifier bottle is not empty Discussion:The humidifier bottle contains aquabides which functions todue humidify oxygen when it is supplied to the respiratory system. This can prevent irritation to the flow of oxygen which has a dry nature. Therefore, during the oxygen administration procedure, the must be filled with aquabidest according to the upper and lower limitshumidifier stated onbottle the bottle. 4.diarrhea A baby6girl, 8 months old, wasAssessment admitted toresults: the children's roommouth with mucosa, complaints of watery times and vomiting. dry lip and stomach skin pinching returns slowly, weight 6 kg, sunken eyes.What is the primary nursing action in this case? A. Measuring daily BB B. Assess skin turgor C. Check the electrolyte value D. Observe the infusion drip E. Monitor intake and output Answer Key: A. Measuring daily weight. Discussion:Babies and younger children will way experience fluid fluid loss that isornot visible. Measuring daily weight is the most accurate to measure gain loss in babies and children. Monitoring intake and output, checking electrolyte values, assessing skin turgor are important interventions, but cannot be measuredor calculating invisible fluid loss. Meanwhile, measuring the circumference of the abdomen and upper arms is more appropriate to determine the nutritional status of babies and children. 5.Assessment A male toddler, 2.5currently years old,experiencing was admitted to the children's room withparents febrileare seizures. results: seizures, temperature 38oC, worried about the child's condition.What is the primary nursing action in this case? A. Wear light clothes B. Observe and document seizure activity C. Remove all dangerous objects near the child D. Allow the seizure to occur and end without interruption E. Lay the child on his side and stay with the child Answer Key: E. Lay the child on his side and stay with the child Discussion:The priority in treating children with seizures is tocanensure safety and protection from injury. Placing the child to sleep on his side prevent the child fromby aspirating fluids/food waste which can enter the lungs during a seizure. Accompanied parents a seizure,toparents can observe and document the seizure incidentwhen so thata child it canhas be reported the doctor as data needed to determine therapy. 6.with A toddler boy, of5 years old, was brought by his mother to thethe community health center complaints diarrhea. Examination results: looks fussy, child looks thirsty and drinks well, eyes are sunken, pulse rate is 110x/minute, respiratory rate is 29x/minute.What action was appropriate to take in this case? A. Refer immediately to the hospital B. Give antibiotics C. Give vitamins D. Give fluids E. Give ORS Answer Key: D. Give fluids Discussion:In the case there is data that is critical in answering the question, namely: - The toddler looks fussy. - The toddler looks thirsty and drinks well. - Sunken eyes. There are twodrinking or more greedily, of the following signs: Restlessness, fussiness / irritability, Sunken eyes, Thirsty, Stomach skin pinching again slowly. This clearly indicates diarrhea with mild/moderate dehydration, so the fluids, actionzinc fallstablets into theand category ofaccording problems where the child is seriously ill. prioritize giving food to the plan.If a more serious problem is found, the intervention will continue for immediate referral. 7.with A male toddler,of2loose yearsstools. old, wasAssessment brought byresults: his mother to thelooks community health center complaints lethargy, weak, does not want to drink, sunken eyes, stomach skin pinching returns slowly, respiratory rate 35x/minute, temperature 38°C.What is the classification of the problem that occurred in this case? A. Diarrhea B. Severe persistent diarrhea C. Diarrhea without dehydration D. Diarrhea with severe dehydration E. Diarrhea with mild dehydration Answer Key: D. Diarrhea with severe dehydration Discussion:In the case there is data that is critical in answering the question, namely - The toddler looks weak and doesn't want to drink. - Awareness of lethargic children. - Sunken eyes. - Stomach skin pinching returns slowly. This is in accordance the basic indicatesigns: severe dehydration diarrhea, namely the with presence of twomanifestations or more of thethat following - Lethargic or unconscious. - Sunken eyes. - Can't drink or don't want to drink. - Stomach skin pinching returns very slowly. 8.looked A baby, 4 daysAssessment old, was admitted to the perinatology room with complaints that the baby yellow. results: yellow appearance, weak sucking reflex, dry skin, respiratory ratetreatment. 48x/minute, pulse rate 112x/minute,is temperature 36.6°C, weight loss of 2 ounces during Currently, phototherapy being given.What is the main nursing problem that arises in this case? A. Nutritional deficit B. Neurological disorders C. Impaired thermoregulation D. Disruption of skin integrity E. Discontinuity in breastfeeding Answer Key: A. Nutritional deficit Discussion:Case data as the key to answering is: - Weak sucking reflex. - Weight loss. This data isneeds. the main datadata for such babiesasexperiencing nutritional problems thatintegrity are less than the body's Other dry skin also make it possible for skin problems to arise but the priority is related to nutritional problems. 9.fever A female toddler, 2vomiting. years old,Assessment was admitted to theappeared children'sfussy, roomcried withand complaints of for 5 days and results: wanted to leave the room, uncooperative when carrying outtonursing procedures. The nurse will carryit out a temperature check and determine whether use an infrared thermometer so that can be carried out more quickly.What are the ethical principles in this case? A. Justice B. Fidelity C. Veracity D. Accountability E. Nonmaleficence Answer Key: E. Nonmaleficence Discussion:In cases where manifestations oftake hospitalization reactions appear that to indicate the toddler is fussy and afraid. To action, the nurse must pay attention the ofdetrimental the hospitalization reaction. Ifwill thebecome hospitalization reaction is not resolved, itchild's willimpact have a impact, namely it traumatic and can hinder the future development phase.In this case, the appropriate ethical principle to follow is non-maleficence. 10. Ashortness boy, 6 years old, wasExamination admitted toresults: the children's room withheard complaints of coughing and of breath. looked restless, wheezing, respiratory rate 60x/minute, pulse rate 99x/minute, temperature 38.5°C. The nurse will take fulfill oxygen needs.What initial preparations should the nurse make in this case?action to A. Provide informed consent B. Provide a semi-Fowler's position C. Provide a comfortable position D. Give O2according to the needs E. Collaborative administration of bronchodilator drugs Answer Key: A. Provide informed consent Discussion:Inside thebefore nurse will fulfillincluding oxygen needs. This is included in theand planner so it requires preparation action, environmental preparation informed consent. According nursing ethics, mustinformed explain consent. what action will be taken and whether the patienttoagrees or not. Thisnurses is called