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A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine, used for ADHD, can potentially cause liver toxicity. Monitoring liver function tests helps detect any signs of liver damage early on. Choice B, kidney function tests, is not as relevant as atomoxetine primarily affects the liver. Choice C, hemoglobin and hematocrit, is not directly impacted by atomoxetine. Choice D, serum sodium and potassium, is not typically affected by atomoxetine use.
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A nurse is preparing to administer an IM injection to a 3-year-old child. Which of the following statements should the nurse make?
- A. If you don't cry, you can pick out a prize.
- B. This medicine will fix you to make you feel better.
- C. You will only feel a little stick
- D. You can choose which leg you get your medicine in.
Correct Answer: D
Rationale: The correct answer is D because allowing the child to choose which leg they receive the injection in gives them a sense of control and autonomy, reducing anxiety and fear. This empowers the child and can help build trust between the nurse and the child. Choices A and B involve rewards or vague promises, which may not be effective in alleviating the child's fear. Choice C may minimize the pain but does not address the child's potential anxiety.
A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid picking up my baby too often to keep from spoiling him.
- B. I will hang a pastel-colored mobile 24 inches above my baby's crib.
- C. I can use a firm pillow to prop up the bottle when feeding my baby.
- D. I will place a ticking clock nearby to soothe my baby throughout the day.
Correct Answer: B
Rationale: The correct answer is B: "I will hang a pastel-colored mobile 24 inches above my baby's crib." This statement indicates an understanding of the teaching because hanging a mobile can provide visual stimulation for the infant, promoting cognitive development. It also helps in soothing and calming the baby.
Incorrect choices:
A: Incorrect because picking up the baby frequently is not spoiling and is important for bonding and meeting the baby's needs.
C: Incorrect because using a firm pillow to prop up the bottle can be a choking hazard and is not recommended for feeding infants.
D: Incorrect because placing a ticking clock nearby can actually be a suffocation risk and is not recommended for soothing babies.
A nurse is providing teaching to the parent of a 10-month-old infant who is having difficulty eating. The parent is feeding the infant goat milk. Which of the following instructions should the nurse include?
- A. Continue breastfeeding.
- B. Warm the goat milk before feeding.
- C. Switch to soy milk.
- D. Add honey to the milk to improve taste.
Correct Answer: A
Rationale: The correct answer is A: Continue breastfeeding. Breast milk is the ideal source of nutrition for infants under one year old. It provides essential nutrients and antibodies that support the infant's growth and immune system. Goat milk is not recommended as a substitute for breast milk or infant formula due to its different nutrient composition. Continuing breastfeeding will ensure the infant receives the necessary nutrients for proper development. Choice B is incorrect as warming the goat milk does not address the issue of inadequate nutrition. Choice C suggests switching to soy milk, which is also not recommended for infants under one year old due to potential allergenicity. Choice D is incorrect and unsafe as honey should not be given to infants under one year old due to the risk of botulism.
A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the head of the bed at a 30° angle.
- B. Offer sips of water due to having surgery.
- C. Log roll the adolescent every 2 hours.
- D. Assist the adolescent to ambulate 12 hours following surgery.
Correct Answer: C
Rationale: The correct answer is C: Log roll the adolescent every 2 hours. This is important to prevent pressure ulcers and maintain spinal alignment post-surgery. Log-rolling involves turning the patient as a unit to avoid twisting the spine. Maintaining the head of the bed at a 30° angle (choice A) is important for respiratory function but not specific to spinal surgery. Offering sips of water (choice B) is generally appropriate after surgery but not specific to spinal instrumentation. Assisting the adolescent to ambulate (choice D) should be done gradually and with caution, typically starting with sitting on the bedside first, rather than a fixed time frame like 12 hours post-surgery.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Steatorrhea
- B. Fever
- C. Drooling
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Fever. In bacterial pneumonia, the body's immune response leads to fever as a common manifestation due to the infection. This is because the body is trying to fight off the bacterial invasion. Steatorrhea (A) is not typically associated with bacterial pneumonia. Drooling (C) is more commonly seen in conditions affecting the mouth or throat. Tinnitus (D) is a symptom related to the ears and is not typically associated with pneumonia. Therefore, the presence of fever is the most relevant sign in a child with bacterial pneumonia.