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A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is an order to administer Tylenol with Codeine every 3 to 4 hours as needed. The nurse is beginning the shift and reviews the chart below for pain history. Based on the information in the chart, what should the nurse do next?
- A. Administer the Tylenol with Codeine.
- B. Distract the child by giving him breakfast.
- C. Instruct the child to take deep breaths and blow his pain away.
- D. Assess the child again in 1 hour.
Correct Answer: A
Rationale: The FACES score of 4 at 7:00 am indicates pain, and it's been 6 hours since the last dose, warranting medication.
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A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating separation anxiety involving which of the following?
- A. Protest.
- B. Despair.
- C. Regression.
- D. Detachment.
Correct Answer: A
Rationale: The toddler's fussing, crying, and pushing the nurse away when the parents attempt to leave indicate the protest phase of separation anxiety, where the child actively resists separation from caregivers.
An 8-year-old with newly diagnosed diabetes is in the hospital for regulation of diet and medications. The child is using an exchange method for the diet. The nurse should instruct the client that the American Diabetes Association's (ADA's) exchange method for dietary regulation includes:
- A. Choosing food from each exchange list.
- B. Using a scale to weigh all food.
- C. Selecting from lists that group food according to protein, fat, and carbohydrate content.
- D. Carbohydrate counting for each meal and snack.
Correct Answer: C
Rationale: The ADA exchange method groups foods by protein, fat, and carbohydrate content to balance macronutrients. It does not require weighing all food or exclusive carbohydrate counting, though lists are used.
Parents of a 15-year-old state that he is moody and rude. The nurse should advise his parents to:
- A. Restrict his activities.
- B. Discuss their feelings with their child.
- C. Obtain family counseling.
- D. Talk to other parents of adolescents.
Correct Answer: B
Rationale: Open communication helps address adolescent moodiness and fosters understanding.
In planning the discharge for a newborn diagnosed with torticollis (wry neck), the nurse should:
- A. Teach the parent the side effects of botulinum toxin (BOTOX).
- B. Coordinate outpatient physical therapy.
- C. Verify the date for corrective surgery.
- D. Demonstrate the use of positioning wedges for sleep.
Correct Answer: B
Rationale: Physical therapy is the most important part of the child's plan of care. Most cases of torticollis respond to gentle stretching exercises, which can be taught to parents and continued at home.
A client's diagnosis of cystic fibrosis was made 13 years ago, and he has since been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which nursing actions are most important initially?
- A. Placing the client on bed rest and ordering a blood gas analysis.
- B. Ordering a high-calorie, high-protein, low-fat, vitamin-enriched diet and pancreatic granules.
- C. Applying an oximeter and initiating respiratory therapy.
- D. Inserting an I.V. line and initiating antibiotic therapy.
Correct Answer: C
Rationale: Applying an oximeter to assess oxygen saturation and initiating respiratory therapy are critical initial actions to address labored respirations and support respiratory function in a cystic fibrosis patient with acute symptoms.