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A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today, but had to cancel the appointment when the child became ill. The nurse should:
- A. Explain that the medication should be discontinued during illness.
- B. Arrange for the pump to be refilled in the hospital.
- C. Reschedule the pump refill for the day of discharge.
- D. Instruct caregivers to call for a refill when the low-volume alarm sounds.
Correct Answer: B
Rationale: Arranging for the pump to be refilled in the hospital ensures continuous therapy, as interrupting baclofen can cause withdrawal symptoms.
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A 15-year-old has been admitted to the hospital with the diagnosis of acute lymphocytic leukemia. Which of the following signs and symptoms require the most immediate nursing intervention?
- A. Fatigue and anorexia.
- B. Fever and petechiae.
- C. Swollen neck lymph glands and lethargy.
- D. Enlarged liver and spleen.
Correct Answer: B
Rationale: Fever and petechiae indicate infection and bleeding risk, requiring urgent intervention in leukemia due to immunosuppression and low platelets.
A nurse is assessing a child who is mildly mentally retarded. The best indication of how a mentally retarded child is progressing can be obtained by observing him:
- A. At school with his teacher.
- B. At home with his family.
- C. In the clinic with his mother.
- D. Playing soccer with his friends.
Correct Answer: B
Rationale: Observing the child at home provides insight into daily functioning and adaptive behavior in a familiar environment, reflecting progress accurately.
A mother tells the nurse that one of her children has chickenpox and asks what she should do to care for that child. When teaching the mother, the nurse should instruct the mother to help her child prevent:
- A. Acid-base imbalance.
- B. Malnutrition.
- C. Skin infection.
- D. Respiratory infection.
Correct Answer: C
Rationale: Scratching chickenpox lesions can lead to bacterial skin infections, which should be prevented.
The nurse is evaluating a child's skills in self-administering insulin (see figure). The nurse should:
- A. Have the child use both hands on the syringe.
- B. Ask the child to place the needle at a 45 degree angle.
- C. Tell the child to use a site lower on her thigh.
- D. Remind the child to rotate sites.
Correct Answer: D
Rationale: Rotating insulin injection sites prevents lipodystrophy and ensures consistent absorption. Both hands are typically used, a 90-degree angle is standard for children, and site location depends on rotation.
A nurse is assessing the growth and development of a 14-year-old boy. He reports that his 13-year-old sister is 2 inches taller than he is. The nurse should advise the boy that the growth spurt in adolescent boys, compared with the growth spurt of adolescent girls:
- A. Occurs at the same time.
- B. Occurs 2 years earlier.
- C. Occurs 2 years later.
- D. Occurs 1 year earlier.
Correct Answer: C
Rationale: Boys' growth spurts occur about 2 years later than girls', typically around 13-15 years.