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A nurse compares a child's height and weight with standard growth charts and finds the child to be in the 50th percentile for height and in the 45th percentile for weight. The nurse interprets these findings as indicating that the child is:
- A. Average height and weight.
- B. Overweight for height.
- C. Underweight for height.
- D. Abnormal in height.
Correct Answer: A
Rationale: 50th percentile height and 45th percentile weight indicate average growth, as they are close.
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Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine?
- A. What they know about the legal implications of drinking.
- B. The type of alcohol they usually drink.
- C. The reasons they choose to use alcohol.
- D. When and with whom they use alcohol.
Correct Answer: C
Rationale: Understanding the reasons for alcohol use helps address underlying issues and tailor interventions.
Which of the following statements should the nurse use to describe to the parents why their child with leukemia is at risk for infections?
- A. Play activities are too strenuous.
- B. Vitamin C intake is reduced over a period of time.
- C. The number of red blood cells is inadequate for carrying oxygen.
- D. Immature white blood cells are incapable of handling an infectious process.
Correct Answer: D
Rationale: Immature white blood cells in leukemia cannot effectively fight infections, increasing risk. Other options are unrelated.
An 8-year-old child does well after infratentorial tumor removal and is transferred back to the pediatric unit. Although she had been told about having her head shaved, she becomes upset. After exploring the child's feelings, which action should the nurse take?
- A. Ask the child if she'd like to wear a hat.
- B. Reassure the child that her hair will grow back.
- C. Explain to the child's parents that her reaction is normal.
- D. Suggest that the parents buy the child a wig as a surprise.
Correct Answer: A
Rationale: Offering a hat empowers the child to cope with her appearance change, addressing her distress directly.
When explaining to the parents of a child with a hydrocele about the possible cause of the condition, the nurse bases this explanation on the interpretation that a hydrocele is most likely the result of which condition?
- A. Blockage in the inguinal canal that allows fluid to accumulate in epididymis and ductus deferens.
- B. Failure of the upper part of the processus vaginalis to atrophy, allowing accumulation of fluid in the testicle and the peritoneal cavity.
- C. A patent processus vaginalis that results in the collection of fluid along the spermatic cord or tunica vaginalis of the testicle.
- D. An obliterated processus vaginalis that allows fluid to accumulate in the scrotal sac.
Correct Answer: C
Rationale: Patent processus vaginalis leads to fluid collection.
The nurse is teaching the parents of a child with sickle cell disease. To instruct them on how to prevent sickle cell crisis, she should include which instruction?
- A. Restrict the child's fluid intake to less than 1 quart per day.
- B. Start up a 1½ quarts of fluids per day.
- C. Stay away from other teenagers.
- D. Avoid physical activity.
Correct Answer: B
Rationale: Adequate hydration (1½ quarts daily) prevents blood viscosity, reducing the risk of sickle cell crisis. Other options are incorrect or overly restrictive.