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A 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?
- A. Stool containing mucus and blood.
- B. An olive-sized mass in the epigastric region.
- C. Frequent burping accompanied by poor feeding.
- D. Rebound tenderness in the left lower abdominal quadrant.
Correct Answer: B
Rationale: An olive-sized mass suggests pyloric stenosis, a common cause of projectile vomiting.
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A nurse is providing care for a toddler diagnosed with autism spectrum disorder and failure to thrive. What strategy should the nurse employ?
- A. Propose food even if the child shows no interest.
- B. Integrate play activities during meal times.
- C. Establish regular meal times.
- D. Permit a variety of food options.
Correct Answer: C
Rationale: Regular meal times provide structure, aiding nutrition in autism spectrum disorder.
The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Position prone after feeding.
- B. Breastfeed frequently.
- C. Avoid smoke exposure.
- D. Inspect the infant's ears daily.
Correct Answer: C
Rationale: Avoiding smoke exposure reduces eustachian tube irritation, lowering otitis media risk.
A nurse is educating parents about essential dietary modifications for their child, who has recently been diagnosed with celiac disease. Which foods should the nurse include in the list of permissible foods for this child?
- A. Rice
- B. Barley
- C. Rye
- D. Oats
Correct Answer: A
Rationale: Rice is gluten-free and safe for celiac disease, unlike barley, rye, or most oats.
A male adolescent comes to the clinic reporting severe testicular pain that started during a high school football practice. The nurse notes significant redness and swelling of the scrotum. What should the nurse do next?
- A. Provide the adolescent with a urinal for urinary hesitancy
- B. Immediately report the findings to the healthcare provider
- C. Collect a sterile urine sample for culture and sensitivity
- D. Obtain a swab of secretions from the penis and urethra
Correct Answer: B
Rationale: Severe testicular pain with redness and swelling suggests testicular torsion, a medical emergency requiring immediate reporting to the healthcare provider.
An adolescent client reports to the nurse of walking with a limp due to pain localized in the right knee which worsens at night but denies any recent injury or trauma. The nurse observes swelling and tenderness in the right lower thigh and imaging results reveal radial ossification in the soft tissues. What condition should the nurse consider as the probable cause of the findings?
- A. Osteosarcoma
- B. Hemosiderosis
- C. Growing pains
- D. Rhabdomyolysis
Correct Answer: A
Rationale: Symptoms and radial ossification suggest osteosarcoma, a common bone tumor in adolescents.