A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source?
- A. Herself
- B. Her mother
- C. Court order
- D. Legal guardian
Correct Answer: A
Rationale: Contraceptive advice is considered a medically emancipated condition, allowing the 16-year-old to provide her own informed consent. Parental or guardian consent is not required, and a court order is unnecessary for this routine care.
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A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do?
- A. Give him a large cup with ice so it tastes better.
- B. Restrict him to his room until he drinks the GoLYTELY.
- C. Use little cups and make a game to reward him for each cup he drinks.
- D. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.
Correct Answer: C
Rationale: Using small cups and making a game with rewards makes the large volume of GoLYTELY less daunting and encourages compliance. A large cup with ice increases the volume, restriction is punitive, and threats about the practitioner are ineffective and inappropriate.
A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child?
- A. Relief of discomfort
- B. Reassurance that illness is temporary
- C. Prevention of secondary bacterial infection
- D. Avoidance of life-threatening complications
Correct Answer: A
Rationale: Treating fever primarily relieves discomfort using antipyretics and environmental measures. It doesn?t reassure temporariness, prevent bacterial infections, or significantly reduce rare complications like febrile seizures.
A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal?
- A. Tolerated breakfast well
- B. Finished all of breakfast ordered
- C. One pancake, eggs, and 240 ml OJ
- D. No documentation is needed for this age child.
Correct Answer: C
Rationale: Documenting specific intake, like one pancake, eggs, and 240 ml orange juice, provides essential data for assessing caloric needs and eating patterns, critical for cystic fibrosis management. General statements like ?tolerated well? or ?finished all? lack detail, and documentation is always needed.
A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention?
- A. Administering preoperative antibiotic
- B. Verifying that the child and procedure are correct
- C. Ensuring that the toddler has been NPO since midnight
- D. Informing the parents where they can wait during the procedure
Correct Answer: B
Rationale: Verifying the correct child and procedure is the priority to ensure safety and prevent errors. Administering antibiotics is secondary, clear liquids can be given up to 2 hours before surgery, and informing parents about waiting areas is important but not the priority.
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents?
- A. Febrile seizures can result.
- B. Antipyretics may cause malignant hyperthermia.
- C. Antipyretics are of no value in treating hyperthermia.
- D. Liver damage may occur in critically ill children.
Correct Answer: C
Rationale: Antipyretics are ineffective for hyperthermia, as the body?s temperature set point is normal, requiring cooling measures instead. Seizures are linked to fever, not hyperthermia; malignant hyperthermia is unrelated to antipyretics; and while liver damage is a risk with acetaminophen, it?s not the primary reason.
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