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A 9-year-old child with Guillain-Barré syndrome requires mechanical ventilation. Which action should the nurse take?
- A. Maintain the child in a supine position to prevent unnecessary nerve stimulation.
- B. Transfer the child to a bedside chair three times a day to prevent postural hypotension.
- C. Engage the child in vigorous passive range-of-motion exercises to prevent loss of muscle function.
- D. Turn the child slowly and gently from side to side to prevent respiratory complications.
Correct Answer: D
Rationale: Turning the child gently prevents respiratory complications like atelectasis while minimizing discomfort in Guillain-Barré syndrome.
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While preparing to examine a 6-week-old infant's scrotal sac and testes for possible undescended testes, which of the following would be most important for the nurse to do?
- A. Check the diaper for recent urination.
- B. Give the infant a pacifier.
- C. Ensure that the room is kept warm.
- D. Tap lightly on the left inguinal ring.
Correct Answer: C
Rationale: Ensuring the room is warm helps relax the cremaster muscle, facilitating examination.
A 13-year-old has been admitted with a diagnosis of rheumatic fever and is on bed rest. He complains of a sore throat. His joints are painful and swollen. He has a red rash on his trunk and is experiencing aimless movements of his extremities. Use the chart below to determine what the nurse should do first.
- A. Report the heart rate to the physician.
- B. Apply lotion to the rash.
- C. Splint the joints to relieve the pain.
- D. Request an order for medication to treat the elevated temperature.
Correct Answer: A
Rationale: Rheumatic fever can cause carditis, and an elevated heart rate may indicate cardiac involvement, requiring immediate reporting. Other symptoms are managed after assessing cardiac status.
Which of the following statements by the mother of an 18-month-old child should indicate to the nurse that the child needs laboratory testing for lead levels?
- A. My child does not always wash after playing outside.
- B. My child drinks 2 cups of milk every day.
- C. My child has more temper tantrums than other kids.
- D. My child is smaller than other kids of the same age.
Correct Answer: A
Rationale: Not washing after outdoor play increases lead exposure risk from contaminated soil or dust, warranting testing. Milk intake, tantrums, and size are not specific indicators.
Which one of the following children is at most risk for sudden infant death syndrome (SIDS)?
- A. Infant who is 3 months old.
- B. 2-year-old who has apnea lasting up to 5 seconds.
- C. First-born child whose parents are in their 40s.
- D. 6-month-old who has had two bouts of pneumonia.
Correct Answer: A
Rationale: A 3-month-old infant is at the highest risk for SIDS, as the peak incidence occurs between 2 and 4 months of age.
Which intervention should the nurse prioritize for an infant with failure to thrive?
- A. Administer IV fluids.
- B. Establish a feeding schedule.
- C. Order a developmental evaluation.
- D. Increase room temperature.
Correct Answer: B
Rationale: A consistent feeding schedule addresses poor intake, promoting weight gain. IV fluids are for acute dehydration, developmental evaluation is secondary, and room temperature is less relevant.