Nokea
A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate?
- A. Request these favorite foods for him.
- B. Identify healthier food choices that he likes.
- C. Explain that he needs fruits and vegetables.
- D. Reward him with ice cream at the end of every meal that he eats.
Correct Answer: A
Rationale: Requesting the child?s favorite foods encourages nutritional intake during illness, which can be supplemented with healthier options. Explaining nutritional needs or rewarding with ice cream is less effective, and focusing only on healthier foods may discourage eating.
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A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?
- A. Use an 18-gauge needle if possible.
- B. Show the child the equipment to be used before the procedure.
- C. If not successful after four attempts, have another nurse try.
- D. Restrain the child completely.
Correct Answer: B
Rationale: Showing the child the equipment before the procedure reduces fear and supports atraumatic care. An 18-gauge needle is too large, a two-try policy (four attempts total) is preferred, and full restraint is unnecessary, favoring therapeutic hugging instead.
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.
Using knowledge of child development, what approach is best when preparing a toddler for a procedure?
- A. Avoid asking the child to make choices.
- B. Plan for a teaching session to last about 20 minutes.
- C. Demonstrate on a doll how the procedure will be done.
- D. Show the necessary equipment without allowing child to handle it.
Correct Answer: C
Rationale: Demonstrating the procedure on a doll engages a toddler?s preoperational thinking through play, reducing fear. Avoiding choices limits participation, 20-minute sessions are too long for a toddler?s attention span, and showing equipment without handling increases anxiety.
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 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20 beats/min less than it was preoperatively. What should be the nurses next action?
- A. Follow the orders and check in 2 hours.
- B. Ask the parents if this is the childs usual heart rate.
- C. Recheck the pulse and blood pressure in 15 minutes.
- D. Notify the surgeon that the child is probably going into shock.
Correct Answer: C
Rationale: A 20 beats/min decrease in heart rate is significant and warrants rechecking pulse and blood pressure in 15 minutes to assess stability. Waiting 2 hours delays intervention, parents may not know the usual rate, and assuming shock without further data is premature.