Nokea
A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately:
- A. Put the client to bed.
- B. Obtain the child's blood pressure.
- C. Notify the physician.
- D. Administer acetaminophen (Tylenol).
Correct Answer: B
Rationale: Symptoms may indicate hypertensive crisis.
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When planning a visit to the parents of an infant who died of sudden infant death syndrome (SIDS) at home, the nurse should visit the parents at which of the following times?
- A. A few days after the funeral.
- B. Two weeks after the funeral.
- C. As soon as the parents are ready to talk.
- D. As soon after the infant's death as possible.
Correct Answer: C
Rationale: Visiting as soon as the parents are ready to talk respects their grieving process and ensures they are emotionally prepared to receive support.
The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor's heated swimming pool to the emergency department. The nurse should assess the child for:
- A. Hypothermia.
- B. Hypoxia.
- C. Fluid aspiration.
- D. Cutaneous capillary paralysis.
Correct Answer: B,C
Rationale: Near-drowning in a heated pool risks hypoxia from oxygen deprivation and fluid aspiration into the lungs, which are critical to assess.
When assessing an infant with an undescended testis, the nurse should be alert for which of the following?
- A. Abnormal lower extremity reflexes.
- B. A history of frequent emesis.
- C. A bulging in the inguinal area.
- D. Poor weight gain.
Correct Answer: C
Rationale: An inguinal bulge may indicate an undescended testis.
The nurse is teaching an adolescent with asthma how to use an inhaler. In which order should the nurse instruct the client to follow the steps from first to last?
- A. Inhale through an open mouth.
- B. Breathe out through the mouth.
- C. Hold the breath for 5 to 10 seconds.
- D. Press the canister to release the medication.
Correct Answer: B,D,A,C
Rationale: Exhale, press canister, inhale, and hold breath ensures proper medication delivery.
After teaching a group of school teachers about seizures, the teachers role-play a scenario involving a child experiencing a generalized tonic-clonic seizure. Which of the following actions, when performed first, indicates that the nurse's teaching has been successful?
- A. Asking the other children what happened before the seizure.
- B. Moving the child to the nurse's office for privacy.
- C. Removing any nearby objects that could harm the child.
- D. Placing a padded tongue blade between the child's teeth.
Correct Answer: C
Rationale: Removing harmful objects first ensures the child's safety during a seizure, reflecting effective teaching.