Nokea
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
- A. Apply lotion to hands and feet.
- B. Encourage the child to rest when possible.
- C. Place the child in a quiet environment.
- D. Make a list of foods that the child likes.
Correct Answer: C
Rationale: A quiet environment reduces sensory stimulation, alleviating irritability, which is a primary concern in Kawasaki disease.
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During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?
- A. Encourage the client to discuss her need for contraceptives with her parents.
- B. Counsel the client about the risks and benefits of using oral contraceptives.
- C. Explain that she needs parental approval to receive contraceptives.
- D. Tell the client how to receive a variety of free oral contraceptives from the clinic.
Correct Answer: B
Rationale: Providing counseling about the risks and benefits of oral contraceptives ensures the client is informed and respects her autonomy and privacy while ensuring she receives necessary information.
The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement.
- B. The child is afebrile with normal vital signs postoperatively.
- C. An intracranial pressure (ICP) monitoring probe is in place.
- D. The child reports no evidence of continuous headaches.
Correct Answer: D
Rationale: The absence of continuous headaches indicates the VP shunt is functioning normally by relieving pressure on the brain, a primary symptom of hydrocephalus.
The parents of a child with Wilms tumor ask the nurse why surgery is necessary before a biopsy is performed. Which information should the nurse provide?
- A. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread.
- B. Metal clips are surgically applied at the tumor site for exact marking for radiation.
- C. Surgery is necessary to stage the tumor and determine metastasis to other sites.
- D. The surgery provides a visualization of other pathology and dysfunction of the kidney.
Correct Answer: A
Rationale: Biopsy risks rupturing the encapsulated Wilms tumor, potentially spreading cancer cells, making surgery the preferred initial approach.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?
- A. The TSH is high because of the low production of T4 by the thyroid.
- B. The thyroxine level is low because the TSH level is high.
- C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
- D. High thyroxine levels normally occur in breastfeeding infants.
Correct Answer: A
Rationale: High TSH levels are a compensatory response to low T4 production, indicating congenital hypothyroidism, which requires prompt treatment to prevent developmental delays.
A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?
- A. Ask the boy to describe a typical day at school.
- B. Compare the child's vital signs over the past three weeks.
- C. Conduct a complete neurological assessment.
- D. Counsel the parents to pay more attention to the child.
Correct Answer: A
Rationale: Describing a typical school day helps identify potential stressors causing the symptoms, guiding further intervention.