Nokea
A 9-year-old is given morphine for postoperative pain. As the nurse is assessing the client for pain 4 hours later, his mother leaves the room and the child begins to cry. The nurse's initial assessment of the child's pain is that he is:
- A. Not in pain because the crying began after the mother leaves.
- B. Less tolerant of pain because he is upset.
- C. In pain because he is crying.
- D. Not in pain because he was medicated 4 hours ago.
Correct Answer: B
Rationale: Emotional distress, such as the mother leaving, can lower pain tolerance, making the child more sensitive to existing pain.
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The nurse should teach the mother of a child who has a new cast for a fractured radius to do which of the following for the first few days at home?
- A. Use a hair dryer to dry the cast more quickly.
- B. Have the child refrain from strenuous activities.
- C. Check movement and sensation of the child's fingers once a day.
- D. Administer acetaminophen every 8 to 12 hours for discomfort.
Correct Answer: B
Rationale: Refraining from strenuous activities prevents damage to the cast and supports healing during the initial recovery period.
When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which of the following?
- A. Ultra-high-frequency sound waves.
- B. Catheter placed in the right femoral vein.
- C. Cutdown procedure to place a catheter.
- D. General anesthesia.
Correct Answer: B
Rationale: Cardiac catheterization involves inserting a catheter, typically through the femoral vein, to assess heart structures. Ultra-high-frequency sound waves are used in echocardiography, a cutdown is not standard, and general anesthesia is not always required.
The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents:
- A. It is only necessary to have the vaccine if your daughter will be living in a dormitory.'
- B. We recommend the vaccine, but it needs to be given as a series of three injections.'
- C. Let's review your records. The vaccine may have already been given a few years ago.'
- D. We highly recommend this vaccine, but we will need to do a pregnancy screening first.'
Correct Answer: C
Rationale: Checking vaccination records confirms whether the MCV4 vaccine, recommended for adolescents, was previously administered.
The mother of a child with Duchenne's muscular dystrophy asks about the chance that her next child will have the disease. The nurse responds based on the understanding of which of the following?
- A. Sons have a 50% chance of being affected.
- B. Daughters have a 1 in 4 chance of being carriers.
- C. Each child has a 1 in 4 chance of developing the disease.
- D. Each child has a 50% chance of being a carrier.
Correct Answer: A
Rationale: Duchenne's muscular dystrophy is X-linked recessive, so sons of a carrier mother have a 50% chance of being affected, while daughters have a 50% chance of being carriers.
An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)?
- A. Administering oral medications.
- B. Administering I.V. morphine.
- C. Obtaining vital signs.
- D. Recording the input and output.
- E. Administering blood products.
- F. Morning hygiene.
- G. Circulation checks.
Correct Answer: A,C,D,F,G
Rationale: LPNs can handle oral medications, vital signs, input/output, hygiene, and circulation checks. I.V. morphine and blood products require RN oversight.