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When assessing an infant with intussusception, what type of stool would the nurse expect to find?
- A. Soft, seedy stool
- B. Currant-jelly stool
- C. Ribbon-like stool
- D. Soft and pasty stool
Correct Answer: B
Rationale: The correct answer is B: Currant-jelly stool. This type of stool, which is red and mucous-like, is a classic sign of intussusception in infants. Choice A (Soft, seedy stool) is incorrect as it does not specifically describe the characteristic stool associated with intussusception. Choice C (Ribbon-like stool) is incorrect; ribbon-like stool may be seen in conditions like colon cancer, not intussusception. Choice D (Soft and pasty stool) is also incorrect as it does not match the typical stool finding in intussusception.
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The school nurse is evaluating the number of school-age children classified as obese. The nurse recognizes that the percentile of body mass index that classifies a child as obese is greater than which?
- A. 50th percentile
- B. 75th percentile
- C. 80th percentile
- D. 95th percentile
Correct Answer: D
Rationale: A child with a BMI greater than the 95th percentile is classified as obese, according to standard growth charts used in pediatric practice.
An anxious 12-year-old child receives an injection from the nurse and sighs with relief when it is done. After a moment of reflection, the girl asks the nurse, 'Is it hard to give someone an injection?' This child's question is evidence that the child has developed which cognitive skill?
- A. Conservation
- B. Accommodation
- C. Decentering
- D. Class inclusion
Correct Answer: C
Rationale: The correct answer is C: Decentering. Decentering is the ability to consider multiple aspects of a situation, which the child's question demonstrates. In this scenario, the child's question shows that she is thinking beyond her own experience and considering the difficulty or complexity of giving an injection from the nurse's perspective. Choices A, B, and D are incorrect. Conservation refers to understanding that certain properties of an object remain the same despite changes in its appearance. Accommodation is the process of adjusting existing knowledge or creating new mental categories to incorporate new information. Class inclusion involves understanding the relationship between a whole set and its subsets, which is not demonstrated in the child's question.
Which best describes signs and symptoms as part of a nursing diagnosis?
- A. Description of potential risk factors
- B. Identification of actual health problems
- C. Human response to state of illness or health
- D. Cues and clusters derived from patient assessment
Correct Answer: D
Rationale: Signs and symptoms are cues and clusters derived from patient assessments that are used to form a nursing diagnosis, guiding the development of a care plan.
After 8 weeks in the neonatal intensive care unit, Chris will soon be discharged. His parents seem apprehensive and worry that he may still be in danger. What is this considered by the nurse?
- A. A common parental reaction
- B. Suggestive of maladaptation
- C. A reason to postpone discharge
- D. Suggestive of inadequate bonding
Correct Answer: A
Rationale: Parents become apprehensive and worried as the time for discharge approaches, which is a common parental reaction. They often have concerns and insecurities about caring for their infant. The worry about potential dangers is a normal adaptive response reflecting the parents' concern for their child's well-being. It is essential for healthcare providers to acknowledge these feelings and support parents in gaining confidence in caring for their infant. Choices B, C, and D are incorrect because the parents' apprehension in this context is a typical emotional response and not indicative of maladaptation, a reason to postpone discharge, or inadequate bonding.
Which distraction technique should be used for an adolescent child during a painful procedure?
- A. Blowing bubbles
- B. Guided imagery
- C. EMLA cream
- D. Sucrose solution
Correct Answer: B
Rationale: The correct answer is B: Guided imagery. Guided imagery is an effective distraction technique for adolescents as it helps them focus on positive mental images instead of the pain. This technique can be a powerful tool in managing pain and anxiety during procedures. Blowing bubbles (choice A) may be more suitable for younger children as it can engage them visually and help distract them. EMLA cream (choice C) is a topical anesthetic and not a distraction technique. Sucrose solution (choice D) is used for pain relief in infants, not typically for adolescents undergoing painful procedures.