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A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?
- A. Ask the boy to describe a typical day at school.
- B. Compare the child's vital signs over the past three weeks.
- C. Conduct a complete neurological assessment.
- D. Counsel the parents to pay more attention to the child.
Correct Answer: A
Rationale: Describing a typical school day helps identify potential stressors causing the symptoms, guiding further intervention.
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The parent of an infant asks when the baby's first immunization for measles, mumps, and rubella (MMR) should be given. Which age should the nurse provide the parent?
- A. 6 months.
- B. 12 months.
- C. 24 months.
- D. 2 months.
Correct Answer: B
Rationale: The CDC recommends the first MMR dose at 12-15 months of age.
The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving this client?
- A. Cross the arms and legs.
- B. Perform a log roll.
- C. Raise the hips.
- D. Flex the knees.
Correct Answer: B
Rationale: The log roll technique maintains spinal alignment, critical after surgical spinal instrumentation.
The nurse is assessing a child with acute glomerulonephritis who presents with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?
- A. Positive rapid strep test of oropharynx.
- B. Blood pressure 88/50 mmHg.
- C. Maculopapular rash over trunk of body.
- D. Weight loss.
Correct Answer: A
Rationale: A positive strep test confirms a recent streptococcal infection, a common cause of acute glomerulonephritis, requiring reporting.
During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?
- A. Encourage the client to discuss her need for contraceptives with her parents.
- B. Counsel the client about the risks and benefits of using oral contraceptives.
- C. Explain that she needs parental approval to receive contraceptives.
- D. Tell the client how to receive a variety of free oral contraceptives from the clinic.
Correct Answer: B
Rationale: Providing counseling about the risks and benefits of oral contraceptives ensures the client is informed and respects her autonomy and privacy while ensuring she receives necessary information.
A child who weighs 18 pounds receives a prescription for amoxicillin 25 mg/kg/day by mouth in divided doses every 12 hours. The bottle is labelled, 'Amoxicillin for Oral Suspension, USP 400 mg per 5 mL.' How many mL should the nurse administer with each dose?
- A. 1.3 mL
Correct Answer: A
Rationale: The dose is calculated as 18 lbs ÷ 2.2 = 8.18 kg, 25 mg/kg/day x 8.18 kg = 204.5 mg/day, divided into 102.25 mg/dose. Then, 102.25 mg ÷ (400 mg/5 mL) = 1.3 mL.