Nokea
A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The parents ask if this behavior is normal. The nurse should explain to the parents that toddlers use ritualistic patterns to:
- A. Establish a sense of identity.
- B. Establish control over adults in their environment.
- C. Establish sequenced patterns of learning behavior.
- D. Establish a sense of security.
Correct Answer: D
Rationale: Ritualistic behaviors in toddlers provide comfort and security.
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A child with a peanut allergy is prescribed an epinephrine auto-injector. The nurse should teach the parents to administer it in which situation?
- A. Mild itching after eating peanuts.
- B. Swelling of the lips and tongue.
- C. Upset stomach after exposure.
- D. Fatigue after a meal.
Correct Answer: B
Rationale: Lip and tongue swelling indicates anaphylaxis, requiring immediate epinephrine. Itching, upset stomach, or fatigue are less severe and managed differently.
An 8-year-old has a body mass index (BMI) for age at the 90th percentile, but has no other risk factors. The nurse should:
- A. Refer for a weight management program.
- B. Prescribe a low-calorie diet.
- C. Order fasting glucose levels.
- D. Initiate daily exercise logs.
Correct Answer: A
Rationale: A BMI at the 90th percentile indicates overweight. A weight management program promotes healthy habits. Diet prescription, glucose testing, or exercise logs are premature without further risk assessment.
When preparing to obtain a neonatal screening test for phenylketonuria (PKU), the neonate must have received which of the following to ensure reliable results?
- A. A feeding of an iron-rich formula.
- B. Nothing by mouth for 4 hours before the test.
- C. Initial formula or breast milk at least 24 hours before the test.
- D. A feeding of glucose water.
Correct Answer: C
Rationale: PKU screening requires protein intake (breast milk or formula) for 24 hours to detect elevated phenylalanine levels. Iron-rich formula, fasting, or glucose water are inadequate.
To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to:
- A. Smile and laugh out loud.
- B. Roll from back to side.
- C. Hold a rattle briefly.
- D. Turn the head from side to side.
Correct Answer: D
Rationale: A 1-month-old can turn their head side to side, a basic motor milestone.
When caring for a child with moderate burns from the waist down, which of the following should the nurse do when positioning the child?
- A. Place the child in a position of comfort.
- B. Allow the child to lie on the abdomen.
- C. Ensure the application of leg splints.
- D. Have the child flex the hips and knees.
Correct Answer: D
Rationale: Flexing hips and knees prevents contractures and promotes circulation in lower extremity burns. Comfort is secondary, lying on the abdomen may cause pressure, and splints are not routinely needed.