Nokea
A child with a lead level of 20 mcg/dL is prescribed oral chelation therapy. The nurse should monitor for which side effect?
- A. Hypertension.
- B. Renal toxicity.
- C. Hypoglycemia.
- D. Seizures.
Correct Answer: B
Rationale: Oral chelators like succimer can cause renal toxicity, requiring monitoring of kidney function. Hypertension, hypoglycemia, and seizures are not common side effects.
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The nurse is assessing the infant shown in the figure. On observing the infant from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani's 'click.'
- B. Limited abduction.
- C. Galeazzi's sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: Asymmetric gluteal folds are a clinical sign of developmental dysplasia of the hip, indicating possible hip dislocation or asymmetry.
After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal?
- A. Encouraging self-care skills in the child.
- B. Teaching the child something new each day.
- C. Encouraging more lenient behavior limits for the child.
- D. Achieving age-appropriate social skills.
Correct Answer: A
Rationale: Promoting self-care skills enhances independence and aligns with developmental goals for children with Down syndrome.
The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which of the responses by the nurse would be most appropriate?
- A. You really shouldn't leave right now. Your child is very sick.
- B. I understand, but feel free to visit or call anytime to see how your child is doing.
- C. It really isn't necessary to stay with your child. We'll take very good care of him.
- D. Can you find someone to stay with your children? Your child needs you here.
Correct Answer: B
Rationale: This response acknowledges the mother's constraints while encouraging involvement.
When developing the plan of care for an infant with myelomeningocele and the parents who have just been informed of the infant's diagnosis, which action should the nurse include as the priority when the parents visit the infant for the first time?
- A. Emphasizing the infant's normal and positive features.
- B. Encouraging the parents to discuss their fears and concerns.
- C. Reinforcing the doctor's explanation of the defect.
- D. Having the parents feed their infant.
Correct Answer: A
Rationale: Highlighting normal features helps parents bond with their infant and fosters a positive perception, which is critical initially after a diagnosis.
The nurse is assessing a neonate with suspected tracheoesophageal fistula. Which of the following findings would be most concerning?
- A. Excessive drooling.
- B. Mild cyanosis during feeding.
- C. Heart rate of 140 bpm.
- D. Temperature of 37°C.
Correct Answer: B
Rationale: Mild cyanosis during feeding indicates potential airway compromise, a critical concern in TEF.