Nokea
A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?
- A. The diaper area shows severe skin breakdown
- B. The mother states the baby is irritable during feedings
- C. The mother is a single parent and lives with her parents
- D. The infant's formula has been changed twice
Correct Answer: A
Rationale: Severe diaper dermatitis causes discomfort, impacting sleep and requiring immediate care.
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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 consume a source of sugar if which symptom occurs?
- A. Seeing spots
- B. Profuse perspiration
- C. Racing pulse
- D. Excessive thirst
Correct Answer: B
Rationale: Profuse perspiration indicates hypoglycemia, requiring sugar intake to raise blood glucose.
The nurse is teaching a school-age child with left femoral osteomyelitis and the child's parent before discharge. What instruction should the nurse give related to the initial phase of treatment?
- A. Ensure no weight bearing on the affected extremity
- B. Administer topical antibiotic therapy daily
- C. Schedule ice pack applications to the infected area
- D. Provide passive range of motion exercises
Correct Answer: A
Rationale: No weight bearing prevents further bone damage during the initial treatment phase of osteomyelitis, supporting infection control.
The parents of a 14-month-old child, hospitalized due to febrile seizures, express their concern to the nurse about their child having seizures for life. What information should the nurse share with these parents?
- A. Avoid overstimulation as it can trigger seizure activity.
- B. Assure the parents that the frequency of febrile seizures decreases as the child ages.
- C. Suggest giving the child a sponge bath when the temperature exceeds 100.6°F (38.1°C).
- D. Advise the prophylactic use of Ibuprofen to prevent febrile seizures.
Correct Answer: B
Rationale: Febrile seizures typically decrease with age, often resolving by age 5.
While checking the vital signs of a 10-year-old child who underwent a tonsillectomy earlier in the day, the nurse notices the child swallowing every 2 to 3 minutes. What action should the nurse take next?
- A. Check for signs of teeth clenching or grinding
- B. Inspect the back of the throat
- C. Stimulate the gag reflex by touching the tonsillar pillars
- D. Ask the child to speak to assess for any changes in voice tone .
Correct Answer: B
Rationale: Frequent swallowing may indicate post-tonsillectomy bleeding, requiring throat inspection.
A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Speak to the healthcare provider about instituting physical therapy.
- B. Offer a pacifier for non-nutritive sucking.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Use sterile technique during feedings.
Correct Answer: B
Rationale: Offering a pacifier for non-nutritive sucking promotes oral feeding skills and emotional stability, supporting normal growth and development in infants with gastroschisis repair.