Nokea
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. Compare the child's vital signs over the past three weeks.
- B. Counsel the parents to pay more attention to the child.
- C. Ask the boy to describe a typical day at school.
- D. Conduct a complete neurological assessment.
Correct Answer: C
Rationale: Asking the boy to describe a typical day at school helps identify potential stressors or psychosocial factors contributing to his non-specific symptoms.
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The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
- A. Divide the gluteal area into quarters and give IM into the upper outer quadrant.
- B. Administer the injection into the middle of the lateral aspect of the thigh.
- C. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage.
- D. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.
Correct Answer: B
Rationale: The vastus lateralis in the thigh is the preferred IM site for toddlers, ensuring safe delivery.
The nurse is educating the caregiver of a school-age child who has recently been diagnosed with attention-deficit hyperactivity disorder (ADHD). Which of the caregiver's statements indicate that they have understood the education? (Select all that apply.)
- A. Create an organization chart for tasks.
- B. Understand that nonstimulant medications show little benefit in treatment.
- C. Know that medication is the best approach to treatment.
- D. Designate an established area for study.
- E. Maintain a consistent home schedule.
- F. Anticipate being automatically entered into a specialized education plan.
Correct Answer: A,D,E
Rationale: Organizational charts, a designated study area, and consistent schedules provide structure, benefiting ADHD management.
When developing a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the client to consume a source of sugar if which symptom occurs?
- A. Seeing spots
- B. Profuse perspiration
- C. Racing pulse
- D. Excessive thirst
Correct Answer: B
Rationale: Profuse perspiration indicates hypoglycemia, requiring sugar intake to raise blood glucose.
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
- A. Apply lotion to hands and feet.
- B. Encourage the parents to rest when possible.
- C. Make a list of foods that the child likes.
- D. Place the child in a quiet environment.
Correct Answer: D
Rationale: Placing the child in a quiet environment reduces stimulation and promotes rest, addressing irritability, a primary symptom of Kawasaki disease.
A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Speak to the healthcare provider about instituting physical therapy.
- B. Offer a pacifier for non-nutritive sucking.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Use sterile technique during feedings.
Correct Answer: B
Rationale: Offering a pacifier for non-nutritive sucking promotes oral feeding skills and emotional stability, supporting normal growth and development in infants with gastroschisis repair.