Nokea
A 10-year-old child proudly tells the nurse that brushing and flossing her teeth is her responsibility. The nurse interprets this statement as indicating which of the following about the child?
- A. She is too young to be given this responsibility.
- B. She is most likely capable of this responsibility.
- C. She should have assumed this responsibility much sooner.
- D. She is probably just exaggerating the responsibility.
Correct Answer: B
Rationale: A 10-year-old is capable of taking responsibility for personal hygiene tasks like brushing teeth.
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A nurse is making an initial visit to a family with a 3-year-old child with early Duchenne's muscular dystrophy. Which of the following findings is expected with the missing child?
- A. Contractures of the large joints.
- B. Enlarged calf muscles.
- C. Difficulty riding a tricycle.
- D. Small, weak muscles.
Correct Answer: B
Rationale: Enlarged calf muscles due to pseudohypertrophy are a hallmark of early Duchenne's muscular dystrophy, caused by fatty infiltration of muscle tissue.
A child with a nut allergy is admitted with a severe reaction for the third time in three months. The parent says, 'I am having trouble with the food labels.' The nurse should first:
- A. Assess the parent's ability to read.
- B. Refer the client to the dietician.
- C. Notify the primary care provider.
- D. Obtain a social service consult.
Correct Answer: B
Rationale: A dietician can provide expert guidance on reading labels to avoid allergens. Reading assessment, provider notification, or social services may follow but are not the priority.
Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing severe diarrhea?
- A. Monitoring the total 8-hour formula intake.
- B. Weighing the infant each day.
- C. Checking the anterior fontanel every shift.
- D. Monitoring abdominal skin turgor every shift.
Correct Answer: B
Rationale: Daily weights provide an accurate measure of fluid loss in diarrhea.
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." The nurse should:
- A. Explain that completing a teaching checklist is required by the hospital.
- B. Help the client find information on the Internet.
- C. Provide the client with written information instead.
- D. Explain that information found on the Internet cannot be trusted.
Correct Answer: B
Rationale: Assisting with finding reliable online information respects the adolescent's autonomy.
The nurse is assessing a neonate with suspected tracheoesophageal fistula. Which of the following findings would be most concerning?
- A. Excessive drooling.
- B. Mild cyanosis during feeding.
- C. Heart rate of 140 bpm.
- D. Temperature of 37°C.
Correct Answer: B
Rationale: Mild cyanosis during feeding indicates potential airway compromise, a critical concern in TEF.