Choice A rationale:

Stomatitis, inflammation of the oral mucosa, can make eating painful, leading to inadequate nutritional intake. The discomfort caused by stomatitis can discourage the patient from eating, potentially resulting in malnutrition. Ensuring adequate nutritional intake is crucial to support the patient's immune system and healing during antineoplastic therapy.

Choice B rationale:

Dental caries are not directly related to stomatitis. Stomatitis is inflammation of the oral mucosa, whereas dental caries involve decay of tooth structure due to bacterial action on food debris and sugars.

Choice C rationale:

Diarrhea is unrelated to stomatitis. Diarrhea involves frequent, loose, or watery stools, often caused by gastrointestinal infections, certain medications, or dietary intolerances.

Choice D rationale:

Gingival hyperplasia is an overgrowth of gum tissue and is not a likely result of stomatitis. It can be associated with some medications like anticonvulsants.

Choice D rationale:

Preschool-aged children may fear pain and bleeding, and applying a small dressing after venipuncture helps alleviate anxiety. It provides a sense of control and comfort, as the child perceives their active participation in caring for the site.

Choice A rationale:

Showing the needle and syringe might intensify anxiety in the child, making venipuncture more distressing. It's important to minimize any distress during the procedure.

Choice B rationale:

Allowing the child to help cleanse the site could lead to more anxiety as the child might interpret it as their own responsibility for the procedure.

Choice C rationale:

Encouraging the child to show the site to adults may not be reassuring for the child and could potentially exacerbate their apprehension.

Choice B rationale:

After cleft palate repair, infants should be fed pureed or soft foods to prevent trauma to the surgical site and facilitate healing. These textures minimize the risk of injury and avoid strain on the repaired area.

Choice A rationale:

Allowing the child to self-feed with a spoon can introduce solid textures prematurely and pose a risk of disrupting the surgical repair.

Choice C rationale:

Using a cup with a straw might cause suction that could negatively impact the healing surgical site, increasing the risk of complications.

Choice D rationale:

Restricting breastfeeding is not necessary for cleft palate repair. However, positioning adjustments may be needed to facilitate effective breastfeeding while minimizing stress on the surgical area.

Choice A rationale:

Avoid setting limits or establishing disciplinary guidelines is not appropriate. Children with cognitive impairment require structure and consistent boundaries to ensure their safety and development.

Choice B rationale:

Encouraging the child to socialize with same-aged children is important for their social and emotional development. Interaction with peers fosters communication skills and helps them integrate into society.

Choice C rationale:

Avoid discussing sexuality until the child is an adult may lead to misinformation and confusion. Addressing sexuality in an age-appropriate manner is vital to help the child develop a healthy understanding of their body and relationships.

Choice D rationale:

Encouraging delaying the child's entry into educational programs hinders their cognitive and intellectual growth. Early intervention and tailored educational programs are crucial for children with cognitive impairment to reach their full potential.

Choice A rationale:

High levels of structure will cause behavioral problems is incorrect. Structure and routine often provide a sense of security for children with autism and can help minimize behavioral challenges.

Choice B rationale:

Negative reinforcement works better than positive reinforcement is not accurate. Positive reinforcement is generally more effective in promoting desired behaviors in children with autism.

Choice C rationale:

Strict dietary modifications can sometimes cure autism is a misconception. While a balanced diet can positively impact overall health, there is no dietary cure for autism spectrum disorder.

Choice D rationale:

Level of functioning varies significantly among children with autism is crucial information for parents. Autism is a spectrum disorder, leading to a wide range of abilities and challenges. Tailoring interventions to the child's specific needs is important.

Choice A rationale:

Instructing the mother in palpation of bladder distention might not effectively address the issue of incomplete bladder emptying. Clean intermittent catheterization is a more appropriate technique to ensure complete emptying.

Choice B rationale:

Informing the mother that life-long antibiotic administration will be necessary is not the primary approach. Antibiotics may be required in specific situations, but addressing incomplete emptying is the key focus.

Choice C rationale:

Preparing the mother for the need for urinary diversion surgery is premature. Clean intermittent catheterization is a conservative measure that should be attempted before considering surgical options.

Choice D rationale:

Instructing the mother in the technique of clean intermittent catheterization helps manage the neurogenic bladder's incomplete emptying. This technique reduces the risk of urinary tract infections and promotes bladder health.

Evaluate their readiness to learn.

Choice A rationale:

Limiting the session to 40 minutes might not be the initial step, as it doesn't assess the patient and mother's readiness to learn. Teaching sessions should be tailored to their learning capacity, and time restrictions should come after assessing their readiness.

Choice B rationale:

Having them handle equipment is a valuable step in teaching, but it doesn't address the foundational aspect of assessing their readiness to learn. Jumping straight into equipment handling might not be effective if they are not prepared to absorb the information.

Choice C rationale:

Giving an illustrated book might engage visual learners, but without evaluating their readiness, this approach might not be the most effective starting point. Readiness assessment helps tailor teaching methods to their learning styles and capacities.

Choice D rationale:

Evaluating their readiness to learn is the best initial action. Assessing their understanding, motivation, and any barriers to learning allows the nurse to create a customized teaching plan. This approach enhances the effectiveness of subsequent teaching strategies.

An hour before meals and at bedtime.

Choice A rationale:

Scheduling chest physiotherapy an hour before meals and at bedtime is optimal. This timing helps prevent aspiration during meals and aids in clearing secretions before sleep. It complements the patient's meal schedule and sleep routine.

Choice B rationale:

Every six hours around the clock could disrupt the patient's sleep and meal times. Chest physiotherapy might not align well with the patient's daily activities, potentially affecting treatment compliance and effectiveness.

Choice C rationale:

Performing chest physiotherapy upon awakening and after meals might increase the risk of aspiration during meals. Clearing airways before meals is safer, and performing it right after meals could cause discomfort.

Choice D rationale:

Evenly spaced physiotherapy when awake lacks synchronization with meal and sleep times. This approach might not optimize treatment effects and patient convenience.

Dust the child's room with a damp cloth every week.

Choice A rationale:

Dusting the child's room with a damp cloth weekly is the most appropriate strategy. This minimizes allergen exposure by capturing and removing dust particles instead of dispersing them, as dry dusting might. Consistent, thorough cleaning can help prevent exacerbations.

Choice B rationale:

Providing down pillows might aggravate allergies due to their potential to harbor dust mites and allergens, worsening the child's asthma symptoms.

Choice C rationale:

Using a warm mist humidifier could promote mold growth and allergen accumulation in the room, potentially worsening asthma symptoms rather than alleviating them.

Choice D rationale:

Encouraging the child to go outside in cold air during an asthma attack is not recommended. Cold air can trigger bronchospasms and worsen asthma symptoms, making this strategy potentially harmful.

Choice A rationale:

Waiting to discuss the surgery until the child asks specific questions might lead to increased anxiety as the child may be apprehensive about the surgery but unable to express their concerns.

Choice B rationale:

Setting aside an hour a day to talk about the child's feelings concerning the surgery can be overwhelming for a 5-year-old, potentially increasing anxiety and making the procedure seem more daunting.

Choice C rationale:

Reading the child a story about children of similar age who go to the hospital for surgery provides a developmentally appropriate approach. It helps the child understand the process through relatable characters, reducing fear and uncertainty about the upcoming experience.

Choice D rationale:

Having the child visit a family whose preschool child has just been discharged from the hospital might expose the child to unfamiliar situations, possibly leading to more confusion and anxiety.

Choice A rationale:

While maintaining a moist oral mucosa is important, preventing infection takes precedence, as infections can lead to serious complications and compromise overall health.

Choice B rationale:

Increasing physical mobility is a valid goal, but infection prevention is more critical, especially when starting prednisone therapy, which can weaken the immune response.

Choice C rationale:

The priority lies in keeping the patient free of infection. Prednisone can suppress the immune system, making the patient more susceptible to infections that can have severe consequences.

Choice D rationale:

Ingesting a moderate potassium diet is important, but the prevention of infection takes precedence due to the potential for serious health risks associated with compromised immunity.

Choice A rationale:

Priority consideration should be given to the child's intolerance of strangers, as it directly impacts the child's safety and comfort in the hospital environment.

Choice B rationale:

Increasing modesty is a normal developmental aspect, but it doesn't take precedence over safety concerns or the immediate hospital care needs.

Choice C rationale:

Having imaginary companions is a common behavior in children and is not an immediate priority in planning care.

Choice D rationale:

While the child's preference for others making decisions might be a consideration, it is not as urgent as addressing the child's intolerance of strangers, which can affect the child's emotional well-being and cooperation during hospitalization.

Minimize crying.

Choice A rationale:

Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.

Choice B rationale:

Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.

Choice C rationale:

Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.

Choice D rationale:

Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.

Have a child life specialist explain the procedure using a doll.

Choice A rationale:

Having a child life specialist explain the procedure using a doll is the best approach for preparing a 4-year-old for a bone marrow aspiration. This method utilizes play therapy to help the child understand the procedure in a developmentally appropriate and non-threatening way.

Choice B rationale:

Giving the client color handouts might not effectively engage a 4-year-old's attention and understanding. Young children often benefit more from interactive and visual methods like using a doll.

Choice C rationale:

Telling the client that other children have had the procedure might not alleviate the child's anxiety or fear. Concrete explanations and visual aids are more effective in reducing anxiety and helping the child cope.

Choice D rationale:

Allowing the patient to watch a video of the procedure on another child could potentially increase anxiety and fear. Children might not fully comprehend the video and could misinterpret it, leading to more distress. Interactive methods are more effective.

Choice A rationale:

Placing the patient in halo traction is not applicable for a scoliosis correction surgery with Harrington rods. Halo traction is typically used for cervical spine injuries or deformities, not for scoliosis correction.

Choice B rationale:

The correct answer. After Harrington rod insertion, maintaining proper alignment is crucial to prevent complications. Using a log-roll technique when turning the patient helps maintain spinal alignment and prevent stress on the surgical site.

Choice C rationale:

Keeping the patient nothing by mouth for 72 hours is not typically necessary after scoliosis surgery. Clear fluids and a light diet are usually initiated shortly after surgery.

Choice D rationale:

Restricting visitors for 48 hours is not a standard practice after scoliosis surgery unless there are specific infection control concerns, which are not mentioned in the scenario.

Choice A rationale:

Baclofen from an intrathecal pump primarily affects muscle tone and spasticity, not seizure medications .

Choice B rationale:

Baclofen use generally leads to a reduction in dystonia , not an increase. It's used to manage spasticity, not exacerbate it.

Choice C rationale:

The correct answer. Baclofen administered via an intrathecal pump is intended to reduce muscle tone and spasticity, improving mobility and comfort for patients with conditions like cerebral palsy.

Choice D rationale:

Baclofen doesn't typically cause decreased mobility . In fact, its use is expected to enhance mobility by reducing spasticity.

Choice A rationale:

While educating caregivers on sensory impairment is important for an infant with myelomeningocele, preventing infection takes precedence as the priority nursing intervention.

Choice B rationale:

The correct answer. Preventing infection at the site of the myelomeningocele is crucial to avoid potentially life-threatening complications, such as meningitis. The exposed neural tissue poses a significant infection risk.

Choice C rationale:

Correcting joint contractures is important but is a secondary concern compared to preventing infection, which can have more immediate and severe consequences.

Choice D rationale:

Measuring daily head circumference is important to monitor for hydrocephalus in these infants, but preventing infection remains the higher priority.

Choice A rationale:

Educating caregivers on sensory impairment is important in the care of a child with myelomeningocele, but the priority is to prevent infection. The exposed spinal cord and tissue are at risk of infection.

Choice B rationale:

Preventing infection is the priority for a child with myelomeningocele. The neural tube defect exposes the spinal cord, making the child susceptible to infections that can lead to serious complications.

Choice C rationale:

Correction of joint contractures is important in the overall care of a child with myelomeningocele, but preventing infection takes precedence. Joint contractures can be managed over time, while infection can quickly escalate.

Choice D rationale:

Measuring daily head circumference is essential for assessing hydrocephalus in a child with myelomeningocele, but preventing infection is more urgent. Infection can cause rapid deterioration, while changes in head circumference might be gradual.

Choice A rationale:

The varicella vaccine is not contraindicated solely based on Down Syndrome. It is important for these children to receive immunizations due to potential increased susceptibility to infections.

Choice B rationale:

A 6-month-old developmentally appropriate infant should receive the varicella vaccine according to the recommended schedule. There is no contraindication for this population.

Choice C rationale:

The varicella vaccine might be contraindicated for a child with autism due to concerns about adverse reactions, as these children might have sensitivities to certain vaccine components.

Choice D rationale:

The varicella vaccine should be contraindicated for a 10-year-old with acquired immune deficiency syndrome (AIDS) due to their compromised immune system. Live vaccines like varicella are usually avoided in immunocompromised individuals.

Choice E rationale:

A 12-year-old child with an arm fracture can still receive the varicella vaccine as it is not contraindicated based solely on this condition.

Choice A rationale:

Taking the medication each night at bedtime is not recommended, as stimulant medications can interfere with sleep. Administering them before bedtime can lead to insomnia.

Choice B rationale:

The medication's dosing frequency every 12 hours is not accurate for ADHD stimulant medications. They are typically taken in the morning and may have shorter-acting formulations for later in the day if needed.

Choice C rationale:

Taking the medication 30 minutes before breakfast is a common instruction for stimulant medications used to treat ADHD. This timing aligns with the child's daily routine and helps manage potential appetite suppression.

Choice D rationale:

Taking the medication with every meal is not recommended, as it might interfere with absorption and effectiveness. Stimulant medications are typically taken in the morning and, if necessary, at lunchtime.

Choice A rationale:

Administering a bolus of intravenous (IV) fluids might be necessary for severe dehydration, but in mild dehydration, oral rehydration is preferred as it avoids potential complications associated with IV fluids.

Choice B rationale:

Offering clear fluids, popsicles, and gelatin is appropriate, but this choice does not specifically address rehydration, which is the primary concern in mild dehydration.

Choice C rationale:

Offering oral rehydration solution (ORS) in small, frequent amounts is the most appropriate intervention for mild dehydration secondary to diarrhea. ORS contains the right balance of electrolytes and fluids to rehydrate without overwhelming the gastrointestinal tract.

Choice D rationale:

Keeping the child on a strict BRAT diet (bananas, rice, applesauce, toast) is an outdated approach. While BRAT foods can be tolerated during mild illness, they lack the necessary electrolytes and fluids to effectively rehydrate.

Choice A rationale:

This response acknowledges the client's feelings, addresses the immediate situation, and offers an alternative without judgment.

Choice B rationale:

Asking "What's wrong? Haven't you ever lost a game before?”. might come across as dismissive and insensitive to the client's emotions.

Choice C rationale:

Simply saying "I am sure you'll win the next game”. minimizes the client's feelings and does not address the current situation.

Choice D rationale:

Telling the client that "other children will not want to play with you if you act like that”. is a negative and shaming response, which is counterproductive to building a therapeutic relationship.

Choice A rationale:

Planning for nurses to provide feedings is not necessary since this is not related to the nursing care plan and doesn't address the mother's concern.

Choice B rationale:

Reporting the finding to the health care provider is appropriate because vomiting after surgical repair of hypertrophic pyloric stenosis could indicate a potential complication or issue.

Choice C rationale:

Assuring the mother that vomiting after surgical repair is normal might not be accurate and could dismiss a potentially significant concern.

Choice D rationale:

Telling the mother it is all right to feel anxious doesn't address the vomiting concern directly and might not be the most pertinent response at this time.

Choice A rationale:

Pancreatic enzymes are used to aid in digestion and are not known to interact significantly with serum creatinine levels. Therefore, they are unlikely to be contraindicated based solely on an elevated serum creatinine level.

Choice B rationale:

Gentamicin is an aminoglycoside antibiotic that is primarily eliminated by the kidneys. Elevated serum creatinine levels indicate potential renal impairment, which could lead to reduced drug clearance and an increased risk of gentamicin toxicity, including nephrotoxicity and ototoxicity. Consulting the health care provider before administering gentamicin is important to ensure the appropriateness of the medication dosage and regimen.

Choice C rationale:

Albuterol is a bronchodilator commonly used to treat respiratory conditions. Serum creatinine levels are not directly related to albuterol administration. It is unlikely that an elevated serum creatinine level would significantly affect the administration of albuterol.

Choice D rationale:

Carbenicillin is an antibiotic that is excreted through the kidneys. While renal function may impact the dosing of carbenicillin, an elevated serum creatinine level alone may not necessarily warrant consultation with the health care provider. Other factors such as the severity of renal impairment and the patient's overall condition would need to be considered.

Choice A rationale:

Monitoring the stool consistency is a crucial nursing action to assess the effectiveness of pancreatic enzyme replacement therapy. Patients with pancreatic insufficiency, such as those with cystic fibrosis, may have difficulty digesting fats properly. Improved stool consistency, specifically a reduction in greasy and foul-smelling stools, indicates that the pancreatic enzymes are aiding in fat digestion.

Choice B rationale:

Pupillary reflex response assessment is unrelated to pancreatic enzyme replacement therapy. It is more commonly performed to assess neurological status or the effects of medications affecting the autonomic nervous system.

Choice C rationale:

Listening to breath sounds is important for assessing respiratory status, but it does not directly reflect the effectiveness of pancreatic enzyme replacement therapy.

Choice D rationale:

Auscultating the apical pulse rate is a general assessment of cardiovascular function and does not provide information about the effectiveness of pancreatic enzyme replacement therapy.