Nokea
A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?
- A. Report the findings immediately to the healthcare provider.
- B. Obtain a swab of secretions from the penis and urethra.
- C. Collect a sterile urine sample for culture and sensitivity.
- D. Provide the adolescent with a urinal for urinary hesitancy.
Correct Answer: A
Rationale: Significant erythema and swelling suggest testicular torsion, a medical emergency requiring immediate reporting.
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A 9-week-old infant is scheduled for a cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. White blood cell count of 10,000/mm (10x 10/L).
- B. Weight gain of 2 pounds (0.91 kg) since birth.
- C. Red blood cell count of 2.3 cell/mcl or (2.3 x 10/L).
- D. Urine specific gravity is 1.011.
Correct Answer: C
Rationale: A low red blood cell count indicates anemia, increasing surgical risks, making it critical to report to the surgeon.
The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement(s) made by the caregiver demonstrate an understanding of the education?
- A. Understanding that nonstimulant medications show little benefit in treatment.
- B. Designating an established area for study.
- C. Anticipating being automatically entered into a specialized education plan.
- D. Knowing that medication is not always the best approach to treatment.
- F. Maintaining a consistent home schedule.
Correct Answer: B,D,F
Rationale: Designating a study area, recognizing non-medication approaches, and maintaining a consistent schedule support ADHD management, while nonstimulants can be effective, and IEPs are not automatic.
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 eat a source of sugar if which symptom occurs?
- A. Racing pulse.
- B. Profuse perspiration.
- C. Excessive thirst.
- D. Seeing spots.
Correct Answer: B
Rationale: Profuse perspiration is a symptom of hypoglycemia, requiring immediate sugar intake to raise blood glucose levels.
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?
- A. 1.8 mL
Correct Answer: A
Rationale: The dose is calculated as 30 kg x 0.3 mg/kg = 9 mg. Dividing by 5 mg/mL gives 1.8 mL, which is the correct volume to administer.
A 1-year-old child with respiratory syncytial virus (RSV) has been admitted to the pediatric unit. The nurse observes that the child has a fever, rhinorrhea, frequent coughing, and sneezing. Which additional finding should alert the nurse that the child is in acute respiratory distress?
- A. Flaring of the nares.
- B. Bilateral bronchial breath sounds.
- C. Diaphragmatic respirations.
- D. A resting respiratory rate of 35 breaths/min.
Correct Answer: A
Rationale: Nasal flaring indicates increased respiratory effort, a sign of acute respiratory distress.