Nokea
A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. What is the most appropriate nursing action?
- A. Refer him for immediate medical evaluation
- B. Administer analgesics and recommend scrotal support.
- C. Apply an ice bag and observe for increasing pain.
- D. Reassure the adolescent that occasional pain is common with the changes of puberty.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A parent brings their 2-year-old son in for a well visit. The nurse assesses his growth since the last appointment. Which finding should concern the nurse?
- A. Prominent abdomen
- B. Forward curve of the spine in the sacral area
- C. Increase in height of 5 inches in the past year
- D. Total weight gain of 15 lb in the past year
Correct Answer: D
Rationale: The correct answer is D. A total weight gain of 15 lb in one year for a 2-year-old is excessive and may indicate an underlying issue such as a metabolic disorder or overfeeding. This rapid weight gain can put the child at risk for health problems. Choices A, B, and C are not typically concerning findings in a 2-year-old. A prominent abdomen can be normal at this age due to a toddler's slightly protruding belly, a forward curve of the spine at the sacral area is a typical finding in young children, and an increase in height of 5 inches in a year is within the expected range of growth for a 2-year-old.
What is the most critical physiologic change required of newborns at birth?
- A. Transition from fetal to neonatal breathing
- B. Body temperature maintenance
- C. Stabilization of fluid and electrolytes
- D. Closure of fetal shunts in the heart
Correct Answer: A
Rationale: The correct answer is A: Transition from fetal to neonatal breathing. The onset of breathing is the most immediate and critical physiologic change required for the transition to extrauterine life. Factors that interfere with this normal transition increase fetal asphyxia, which is a condition of hypoxemia, hypercapnia, and acidosis. While body temperature maintenance, stabilization of fluid and electrolytes, and closure of fetal shunts in the heart are crucial changes in the transition to extrauterine life, breathing and the exchange of oxygen for carbon dioxide must take precedence as they are essential for newborn survival.
The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate?
- A. Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed.
- B. Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur.
- C. Discourage parent presence during procedures on infants and toddlers.
- D. Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.)
- A. The child has a stiff neck.
- B. The fever is over 40.6 C (105 F).
- C. The child is younger than 2 months.
- D. All of the above
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Clinical manifestations of sodium excess (hypernatremia) include which signs or symptoms?
- A. Hyperreflexia
- B. Abdominal cramps
- C. Cardiac dysrhythmias
- D. Dry, sticky mucous membranes
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.