Nokea
A nurse evaluates discharge teaching as successful when the parents of a school-age child with a ventriculoperitoneal shunt insertion identify which sign as signaling a blocked shunt?
- A. Decreased urine output with stable intake.
- B. Tense fontanel and increased head circumference.
- C. Elevated temperature and reddened incisional site.
- D. Irritability and increasing difficulty with eating.
Correct Answer: D
Rationale: Irritability and difficulty eating are early signs of shunt blockage due to increased intracranial pressure, which parents should recognize for timely intervention.
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After teaching the mother of a 2-year-old child with lactose intolerance about which dairy products to include in the child's diet, which of the following if stated by the mother indicates effective teaching?
- A. Ice cream.
- B. Creamed soups.
- C. Pudding.
- D. Cheese.
Correct Answer: D
Rationale: Hard cheeses (e.g., cheddar) are low in lactose and often tolerated. Ice cream, creamed soups, and pudding have high lactose content, causing symptoms.
The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
- A. A family history of sudden infant death syndrome (SIDS).
- B. A fever of 38.5°C following the 4-month vaccinations.
- C. An acute bilateral ear infection.
- D. Living with a family member who is immunosuppressed.
Correct Answer: C
Rationale: An acute infection is a contraindication for vaccination due to the risk of adverse reactions.
A mother has heard that several children have been diagnosed with mononucleosis. She asks the nurse what ascendancy what precautions should be taken to prevent this from occurring in her child. The nurse should instruct the mother to:
- A. Take no particular precautionary measures.
- B. Sterilize the child's eating utensils before they are reused.
- C. Wash the child's linens separately in hot, soapy water.
- D. Wear masks when providing direct personal care.
Correct Answer: A
Rationale: Mononucleosis spreads through saliva, but routine hygiene is sufficient; no special precautions are needed.
A nurse is teaching the family of an 8-year-old boy with acute lymphocytic leukemia about appropriate activities. Which of the following activities should the nurse recommend?
- A. Home schooling.
- B. Restriction from participating in athletic activities.
- C. Avoiding trips to the shopping mall.
- D. Being treated as 'normal' as much as possible.
Correct Answer: D
Rationale: Normal activities promote psychological well-being in leukemia, with precautions for infection and bleeding risks.
An adolescent male client scheduled for an emergency appendectomy is to be transferred directly from the emergency room to the operating room. Which of the following statements by the client should the nurse interpret as most significant?
- A. I'm scared about the surgery.
- B. I need to call my parents first.
- C. My pain is getting worse.
- D. I don't want to have a scar.
Correct Answer: C
Rationale: Worsening pain may indicate perforation, requiring urgent attention.