Nokea
A nurse is assessing a child who is mildly mentally retarded. The best indication of how a mentally retarded child is progressing can be obtained by observing him:
- A. At school with his teacher.
- B. At home with his family.
- C. In the clinic with his mother.
- D. Playing soccer with his friends.
Correct Answer: B
Rationale: Observing the child at home provides insight into daily functioning and adaptive behavior in a familiar environment, reflecting progress accurately.
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The health care provider has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:
- A. I will request an order for a sedative to help him relax.
- B. I can't do anything to reduce the pain
- C. but you can hold him during the procedure.
- D. I will get an order for a lidocaine-based lubricant to make the procedure more comfortable.
- E. I can apply a topical anesthetic 20 minutes before placing the catheter.
Correct Answer: D
Rationale: Topical anesthetics can minimize discomfort.
The father of a 16-month-old child calls the clinic because the child has a low-grade fever, cold symptoms, and a hoarse cough. Which of the following should the nurse suggest that the father do?
- A. Offer extra fluids frequently.
Correct Answer: A
Rationale: Offering extra fluids frequently helps keep the child hydrated and may soothe the throat, alleviating symptoms of croup.
The nurse is teaching an adolescent with asthma how to use an inhaler. In which order should the nurse instruct the client to follow the steps from first to last?
- A. Inhale through an open mouth.
- B. Breathe out through the mouth.
- C. Hold the breath for 5 to 10 seconds.
- D. Press the canister to release the medication.
Correct Answer: B,D,A,C
Rationale: Exhale, press canister, inhale, and hold breath ensures proper medication delivery.
An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?
- A. Cover the adolescent's legs with blankets.
- B. Report this finding to the physician immediately.
- C. Reposition the adolescent's legs.
- D. Lay the adolescent flat to aid circulation.
Correct Answer: A
Rationale: Cool extremities indicate poor circulation, common in spinal cord injury; covering with blankets promotes warmth and comfort.
A parent asks why it is recommended that the second dose of the measles, mumps, and rubella (MMR) vaccine be given at 4 to 6 years of age? The nurse should explain to the parent that the second dose is given at this age for what reason?
- A. If the child has not developed immunity and becomes pregnant when receiving the vaccine, the risks to the fetus are high.
- B. The chance of contracting the disease is much lower at this age.
- C. The dangers associated with a strong reaction to the vaccine are increased at this age.
- D. A serious complication from the vaccine is swelling of the joints.
Correct Answer:
Rationale: The second MMR dose ensures long-term immunity, as some children may not respond fully to the first dose.