Nokea
A 2-year-old tells his mother he is afraid to go to sleep because 'the monsters will get him.' The nurse should tell his mother to:
- A. Allow him to sleep with his parents in their bed whenever he is afraid.
- B. Increase his activity before he goes to bed, so he eventually falls asleep from being tired.
- C. Give him a favorite cuddly animal or a blanket.
- D. Allow him to stay up an hour later with the family until he falls asleep.
Correct Answer: C
Rationale: A comfort object helps a toddler feel secure and supports self-soothing.
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When providing intermittent nasogastric feedings to an infant with failure to thrive, which method is preferred to confirm tube placement before each feeding?
- A. Obtain a chest X-ray.
- B. Verify that the gastric pH is less than 5.5.
- C. Auscultate the stomach while instilling an air bolus.
- D. Compare the tube insertion length to a standardized chart.
Correct Answer: B
Rationale: Gastric pH <5.5 confirms stomach placement non-invasively. X-rays are impractical for each feeding, auscultation is unreliable, and length comparison doesn't verify placement.
When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki disease, which of the following should be the priority?
- A. Taking vital signs every 6 hours.
- B. Monitoring intake and output every hour.
- C. Minimizing skin discomfort.
- D. Providing passive range-of-motion exercises.
Correct Answer: B
Rationale: Monitoring intake and output hourly is critical in Kawasaki disease to assess for fluid balance and potential cardiac complications like coronary artery involvement.
A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child?
- A. Enjoys physical demonstrations of affection.
- B. Is selfish and insensitive to the welfare of others.
- C. Is uncooperative in play and school.
- D. Has a strong sense of justice and fair play.
Correct Answer: D
Rationale: A 10-year-old typically develops a sense of fairness and justice in social interactions.
A nurse who witnesses an accident involving an adolescent riding a motorcycle, hitting a tree, and being thrown 30 feet into a field stops to help. The adolescent reports that he is now unable to move his legs. While waiting for the emergency medical service to arrive, what should the nurse do?
- A. Flex the adolescent's knees to relieve stress on his back.
- B. Leave the adolescent as he is, staying close by.
- C. Remove the adolescent's helmet as soon as possible.
- D. Assess the adolescent for abdominal trauma.
Correct Answer: B
Rationale: Immobilizing the adolescent by leaving him undisturbed prevents further spinal cord damage until EMS arrives.
A 2-year-old child brought to the clinic by her parents is uncooperative when the nurse tries to look in her ears. Which of the following should the nurse try first?
- A. Ask another nurse to assist.
- B. Allow a parent to assist.
- C. Wait until the child calms down.
- D. Restrain the child's arms.
Correct Answer: B
Rationale: Parental involvement can comfort the child and improve cooperation.