Nokea
A male adolescent comes to the clinic reporting severe testicular pain that started during a high school football practice. The nurse notes significant redness and swelling of the scrotum. What should the nurse do next?
- A. Provide the adolescent with a urinal for urinary hesitancy
- B. Immediately report the findings to the healthcare provider
- C. Collect a sterile urine sample for culture and sensitivity
- D. Obtain a swab of secretions from the penis and urethra
Correct Answer: B
Rationale: Severe testicular pain with redness and swelling suggests testicular torsion, a medical emergency requiring immediate reporting to the healthcare provider.
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A 9-week-old infant is scheduled for a cleft lip repair. What information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Urine specific gravity is 1.011
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds (0.91 kg) since birth
- D. Red blood cell count of 2.3 x 10²/L
Correct Answer: D
Rationale: A low red blood cell count indicates anemia, a surgical risk requiring preoperative attention.
The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
- A. Exercise in a swimming pool.
- B. Begin a training program lifting weights and running.
- C. Perform passive range of motion exercises twice daily.
- D. Splint affected joints during activity.
Correct Answer: A
Rationale: Exercising in a swimming pool is low-impact, reduces joint stress, and improves strength and mobility, making it ideal for JIA.
The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving the client?
- A. Flex the knees.
- B. Raise the hips.
- C. Cross the arms and legs.
- D. Perform a log roll.
Correct Answer: D
Rationale: Log rolling maintains spinal alignment, protecting the surgical site during movement.
When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?
- A. Apply soft restraints to all four extremities.
- B. Assess the dorsal surface of the feet for an IV site.
- C. Instruct parents to sing or croon to the infant.
- D. Select a site that is least restrictive to the infant.
Correct Answer: D
Rationale: Choosing a least restrictive site minimizes distress and allows easier movement post-IV insertion.
The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
- A. Demonstrates startle reflex
- B. Plays “peek-a-booâ€
- C. Has doubled birth weight
- D. Turns head to locate sound
Correct Answer: A
Rationale: The startle reflex should disappear by 6 months; its presence suggests neurological issues.