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A child who weighs 30 kg is experiencing a grand mal seizure. The healthcare provider prescribes diazepam 0.3 mg/kg/dose intravenous (IV) STAT. The medication is available in 5 mg/mL vials. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).
- A. 1.8
Correct Answer: A
Rationale: The total dose is 9 mg (30 kg × 0.3 mg/kg). Dividing by the concentration (5 mg/mL) gives 1.8 mL (9 mg ÷ 5 mg/mL).
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The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. What intervention should the nurse implement?
- A. Obtain the essential information as quickly as possible.
- B. Include the child's toy in the collection of information.
- C. Document interactions between the parent and the child.
- D. Ignore the child's behavior, directing Questions to a parent.
Correct Answer: B
Rationale: Using the toy reduces fear, creating a comfortable environment for history collection.
The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
- A. Demonstrates startle reflex
- B. Plays “peek-a-booâ€
- C. Has doubled birth weight
- D. Turns head to locate sound
Correct Answer: A
Rationale: The startle reflex should disappear by 6 months; its presence suggests neurological issues.
When developing a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the client to consume a source of sugar if which symptom occurs?
- A. Seeing spots
- B. Profuse perspiration
- C. Racing pulse
- D. Excessive thirst
Correct Answer: B
Rationale: Profuse perspiration indicates hypoglycemia, requiring sugar intake to raise blood glucose.
An adolescent client reports to the nurse of walking with a limp due to pain localized in the right knee which worsens at night but denies any recent injury or trauma. The nurse observes swelling and tenderness in the right lower thigh and imaging results reveal radial ossification in the soft tissues. What condition should the nurse consider as the probable cause of the findings?
- A. Osteosarcoma
- B. Hemosiderosis
- C. Growing pains
- D. Rhabdomyolysis
Correct Answer: A
Rationale: Symptoms and radial ossification suggest osteosarcoma, a common bone tumor in adolescents.
The nurse is monitoring a child with hydrocephalus who received a 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 reports no evidence of continuous headaches
- C. An intracranial pressure (ICP) monitoring probe is in place
- D. The child is afebrile with normal vital signs postoperatively.
Correct Answer: B
Rationale: Absence of continuous headaches indicates the shunt is relieving brain pressure effectively.