Nokea
A 7-year-old has been diagnosed as mentally retarded. Which of the parents' expectations for their child is realistic?
- A. Difficulty learning.
- B. An IQ below 70.
- C. Deficits in adaptive behavior.
- D. Normal intellectual capacity.
- E. Behavioral problems.
Correct Answer: A,B,C
Rationale: Mental retardation involves difficulty learning, an IQ below 70, and deficits in adaptive behavior, which are realistic expectations for the child's capabilities.
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Which assessment finding in an infant with colic should the nurse prioritize?
- A. Frequent spitting up.
- B. Crying for 3 hours daily.
- C. Weight gain below average.
- D. Fever of 100.4°F.
Correct Answer: D
Rationale: Fever suggests an underlying illness, requiring urgent evaluation. Prolonged crying is typical of colic, but spitting up and slow weight gain are less acute concerns.
The mother of a preschooler reports that her child creates a scene every night at bedtime. The nurse and the mother decide that the best course of action would be to do which of the following?
- A. Allow the child to stay up later one or two nights a week.
- B. Establish a set bedtime and follow a routine.
- C. Encourage active play before bedtime.
- D. Give the child a cookie if bedtime is pleasant.
Correct Answer: B
Rationale: A consistent bedtime routine promotes healthy sleep habits.
After surgery to repair a tracheoesophageal fistula, an infant receives gastrostomy tube feedings. After feeding the infant by this method, the nurse positions the infant with the head elevated for approximately 30 minutes, primarily to help accomplish which of the following?
- A. Promote intestinal peristalsis.
- B. Prevent regurgitation of formula.
- C. Relieve pressure on the surgical site.
- D. Associate eating with a pleasurable experience.
Correct Answer: B
Rationale: Head elevation reduces the risk of formula reflux, protecting the surgical site and airway.
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse's best response?
- A. Newborns cry and cannot be distracted to stop crying.
- B. When faced with a pain, newborns try to roll away from it.
- C. Newborns typically move their whole body in response to pain.
- D. Pain causes the newborn to withdraw the affected part.
Correct Answer: C
Rationale: Newborns exhibit a generalized body response to pain, such as squirming or thrashing.
A 4-year-old has been scheduled for a cardiac catheterization. To help prepare the family the nurse should:
- A. Advise the family to bring the child to the hospital the night before.
- B. Explain that the child will need a large bandage after the procedure.
- C. Discourage bringing favorite toys that might become associated with pain.
- D. Explain that the child may get up as soon as the vital signs are stable.
Correct Answer: B
Rationale: The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. Preparing the child the night before, bringing favorite toys, and explaining activity restrictions are also important but not the primary focus of this choice.