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A child with a brain tumor is less responsive to verbal commands than he was when assessed the previous hour. The nurse should next:
- A. Raise the head of the bed.
- B. Notify the physician.
- C. Administer an analgesic.
- D. Obtain an oximeter reading.
Correct Answer: B
Rationale: Decreased responsiveness indicates worsening neurological status, requiring immediate physician notification for further evaluation.
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An adolescent is on the football team and practices in the morning and afternoon before school starts for the year. The temperature on the field has been high. The school nurse has been called to the practice field because the adolescent is now reporting that he has muscle cramps, nausea, and dizziness. Which of the following actions should the school nurse do first?
- A. Administer cold water with ice cubes.
- B. Take the adolescent's temperature.
- C. Have the adolescent go to the swimming pool.
- D. Move the adolescent to a cool environment.
Correct Answer: D
Rationale: The symptoms suggest heat exhaustion, and the first priority is to move the adolescent to a cool environment to prevent further heat-related complications.
During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which of the following findings should lead the nurse to formulate the nursing diagnosis Risk for infection?
- A. Dialysate leakage.
- B. Granulation tissue.
- C. Increased time for drainage.
- D. Tissue swelling.
Correct Answer: A
Rationale: Leakage increases infection risk.
Parents bring their child to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions should the nurse ask the parents first?
- A. Was the infant sleeping while wrapped in a blanket?
- B. Was the infant lying on his stomach?
- C. What did the infant look like when you found him?
- D. When had you last checked on the infant?
Correct Answer: B
Rationale: Asking if the infant was lying on his stomach is critical, as prone sleeping is a major risk factor for SIDS and could explain the cessation of breathing.
An 8-year-old child with asthma states, 'I want to play some sports like my friends. What can I do?' The nurse responds to the child based on the understanding of which of the following?
- A. Physical activities are inappropriate for children with asthma.
- B. Children with asthma must be excluded from team sports.
- C. Vigorous physical exercise frequently precipitates an asthmatic episode.
- D. Most children with asthma can participate in sports if the asthma is controlled.
Correct Answer: D
Rationale: Most children with asthma can participate in sports if their condition is well-controlled with appropriate medications and trigger management, allowing them to engage in physical activities safely.
A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to:
- A. Observe the child closely.
- B. Allow the child to participate in activities that will not tire him.
- C. Provide for adequate periods of rest between activities.
- D. Encourage someone in the family to be with the child 24 hours a day.
Correct Answer: C
Rationale: Rest is critical in rheumatic fever to reduce cardiac strain and prevent complications like carditis. Observation and limited activities are important, but rest is the priority.