Nokea
A child with a known seizure disorder is hospitalized for an appendectomy. While assisting the child back from the restroom, the child begins tonic-clonic movements. The nurse should take which actions in order of priority from first to last?
- A. Note the time.
- B. Clear the area of potentially harmful objects and pad the head.
- C. Ease the child to the floor.
- D. Roll the child to the side.
Correct Answer: C,B,D,A
Rationale: Easing the child to the floor prevents injury, clearing objects and padding the head ensures safety, rolling to the side maintains airway, and noting the time tracks seizure duration.
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The nurse is assessing a child with celiac disease. Which symptom should the nurse expect?
- A. Constipation.
- B. Abdominal distension.
- C. Fever.
- D. Joint pain.
Correct Answer: B
Rationale: Abdominal distension is a common symptom of celiac disease due to malabsorption and gas. Diarrhea is more typical than constipation, and fever or joint pain are less specific.
An overweight adolescent has been diagnosed with type 2 diabetes. To increase the client's self-efficacy to manage their disease, the nurse should:
- A. Provide the client with a written daily food and exercise plan.
- B. Discuss eliminating junk food in the home with the parents.
- C. Arrange for the school nurse to weigh the child weekly.
- D. Utilize a peer with type 2 diabetes to role model lifestyle changes.
Correct Answer: D
Rationale: Peer role modeling enhances self-efficacy by providing relatable examples of successful disease management. Plans, junk food elimination, and weigh-ins are less empowering without peer support.
The nurse teaches the mother of a young child with Duchenne's muscular dystrophy about the disease and its management. Which of the following statements by the mother indicates successful teaching?
- A. My son will probably be unable to walk independently by the time he is 9 to 11 years old.'
- B. Muscle relaxants are effective for some children; I hope they can help my son.'
- C. When my son is a little older, he can have surgery to improve his ability to walk.'
- D. I need to help my son be as active as possible to prevent progression of the disease.'
Correct Answer: A
Rationale: Children with Duchenne's muscular dystrophy typically lose the ability to walk independently by ages 9 to 11 due to progressive muscle weakness.
After teaching the mother of a 2-year-old child with lactose intolerance about which dairy products to include in the child's diet, which of the following if stated by the mother indicates effective teaching?
- A. Ice cream.
- B. Creamed soups.
- C. Pudding.
- D. Cheese.
Correct Answer: D
Rationale: Hard cheeses (e.g., cheddar) are low in lactose and often tolerated. Ice cream, creamed soups, and pudding have high lactose content, causing symptoms.
When teaching the parents of an older infant with cystic fibrosis (CF) about the type of diet the child should consume, which of the following would be appropriate?
- A. Low-protein diet.
- B. High-fat diet.
- C. Low-carbohydrate diet.
- D. High-calorie diet.
Correct Answer: D
Rationale: A high-calorie diet is appropriate for an infant with cystic fibrosis to meet increased energy needs due to malabsorption and chronic respiratory issues.