Nokea
A 3-year-old boy is hospitalized after falling down the stairs. His mother cries, 'This is all my fault.' Which is the nurse's best response?
- A. Accidents happen; you shouldn't blame yourself.
- B. Falls are one of the most common injuries in this age group.
- C. It might help to install a baby gate on the stairs.
- D. Your son should be proficient at walking down stairs by now.
Correct Answer: B
Rationale: Reassuring the parent that falls are common in young children can help reduce guilt and anxiety.
You may also like to solve these questions
Nurse Kevin is assessing a newborn for developmental dysplasia of the hip (DDH); he would expect to assess which of the following?
- A. Characteristic limp
- B. Ortolani's sign
- C. Symmetrical gluteal folds
- D. Trendelenburg‘s signs
Correct Answer: B
Rationale: Developmental dysplasia of the hip (DDH) is a condition where the hip joint does not properly form in babies and young children. To assess for DDH, healthcare professionals like Nurse Kevin utilize the Ortolani test. Ortolani's sign is a physical exam maneuver where the healthcare provider will gently manipulate the baby's hips to detect if there is a dislocated hip joint. Specifically, the Ortolani maneuver checks for the presence of a "clunk" as the femoral head relocates into the acetabulum, indicating that the hip joint is dislocated. Therefore, during the assessment of a newborn for DDH, Nurse Kevin would expect to assess for Ortolani's sign as it helps in the diagnosis of developmental dysplasia of the hip.
The nurse is teaching a client who will be discharged soon how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling and induration at the wound site. What do these signs suggest?
- A. Infection
- B. Evisceration
- C. Dehiscence
- D. Hemorrhage
Correct Answer: A
Rationale: The presence of redness, swelling, and induration at the wound site are classic signs of infection. Redness is caused by inflammation, swelling occurs due to fluid accumulation in response to infection, and induration refers to the hardening of the tissue, which is a result of the body's immune response. Infections can lead to delayed wound healing, increased pain, and other complications. It is essential to address these signs promptly to prevent further complications and promote healing.
In pediatric rhabdomyosarcoma, stages are dependent on primary site whether favorable or unfavorable. Which of the following sites of involvement is considered unfavorable?
- A. vagina
- B. uterus
- C. testis
- D. paranasal sinuses
Correct Answer: D
Rationale: Paranasal sinuses are considered unfavorable sites in rhabdomyosarcoma staging.
You are meeting parents of a 5-year-old boy; the mother is wondering about the normal sexual behavior of her child. Of the following, the sexual behavior that is considered HIGHLY unusual in this age group is
- A. touching his genitals in public
- B. showing his genitals to others
- C. undressing in public
- D. imitating intercourse or other adult sexual behaviors
Correct Answer: D
Rationale: Imitating adult sexual behaviors is highly unusual and concerning in young children, suggesting possible exposure to inappropriate content or experiences.
Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?
- A. Muscle weakness
- B. Diaphoresis
- C. Tremors
- D. Constipation
Correct Answer: A
Rationale: Following a unilateral adrenalectomy, there is a risk of developing hyperkalemia due to the altered balance of electrolytes. Hyperkalemia is characterized by high levels of potassium in the blood, which can lead to various symptoms. One of the key manifestations of hyperkalemia is muscle weakness. This occurs because high potassium levels can disrupt the normal function of skeletal muscles, leading to weakness and potentially affecting motor function. Therefore, the nurse would assess for muscle weakness as a sign of hyperkalemia in a patient following a unilateral adrenalectomy. Options B, C, and D are not typically associated with hyperkalemia.