Nokea
A nurse is assessing an infant with failure to thrive. Which finding requires immediate intervention?
- A. Weight below 5th percentile.
- B. Heart rate of 180 bpm.
- C. Poor feeding for 1 week.
- D. Dry mucous membranes.
Correct Answer: B
Rationale: A heart rate of 180 bpm suggests distress (e.g., dehydration, sepsis), requiring urgent evaluation. Low weight, poor feeding, and dry membranes are concerning but less acute.
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The nurse is assessing a child with suspected appendicitis. Which physical finding supports this diagnosis?
- A. Rebound tenderness in the right lower quadrant.
- B. Soft, non-tender abdomen.
- C. Frequent bowel movements.
- D. Generalized abdominal bloating.
Correct Answer: A
Rationale: Rebound tenderness is a key sign of appendicitis due to peritoneal irritation.
After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the father states which of the following?
- A. There is no rectal opening for stool to pass.
- B. There is a tube between the trachea and esophagus.
- C. The nerves at the end of the large colon are missing.
- D. The muscle below the stomach is too tight.
Correct Answer: C
Rationale: Hirschsprung's disease is characterized by absent nerve cells in the distal colon.
While assessing a preschooler brought by her parents to the emergency department after ingestion of kerosene, the nurse should be alert for which of the following?
- A. Uremia.
- B. Hepatitis.
- C. Carditis.
- D. Pneumonitis.
Correct Answer: D
Rationale: Kerosene ingestion often causes chemical pneumonitis due to aspiration risk. Uremia, hepatitis, and carditis are not common complications.
At the 2 week well-child visit a parent states, 'My baby seems to keep his head tilted to the right.' The nurse should further assess the:
- A. Fontanel.
- B. Cervical vertebrae.
- C. Trapezius muscle.
- D. Sternocleidomastoid muscle.
Correct Answer: D
Rationale: Torticollis is commonly caused by tightness or shortening of the sternocleidomastoid muscle, which should be assessed for asymmetry or tightness.
A father brings his 4-week-old son to the clinic for a checkup, stating that he believes his son's testicle is missing. Which of the following explanations would be most appropriate?
- A. Although the testes should have descended by now
- B. it is not a cause for worry.
- C. The testes often do not descend until age 6 months
- D. but let's check to see whether the testes are present.
- E. The testes are present in the scrotal sac at birth
- F. but surgery can remedy the situation.
- G. Although the testes normally descend by 1 year of age
Correct Answer: B
Rationale: Testes often descend by 6 months of age; however, if they haven't, surgical intervention may be necessary.