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A nurse is assisting with the care of an infant who requires emergency surgery and whose parent is an emancipated adolescent. Which of the following people can sign the informed consent form for the procedure?
- A. The parent of the adolescent parent
- B. The adolescent parent
- C. The infant's provider
- D. The adult sibling of the adolescent parent
Correct Answer: B
Rationale: An emancipated adolescent parent has legal authority to consent for their child's procedure. Others lack this authority unless legally designated.
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A nurse is reinforcing teaching with the parent of a child who is newly diagnosed with diabetes mellitus. Which of the following guidelines should the nurse include?
- A. Your child should increase carbohydrate intake when sick.
- B. You should omit your child's bedtime snack.
- C. Your child's meal plan should consist mainly of proteins.
- D. Your child's meal plan should include a snack before physical activity.
Correct Answer: D
Rationale: A snack before activity prevents hypoglycemia. Increased carbs when sick requires guidance, bedtime snacks prevent overnight lows, and meals should balance nutrients, not focus on proteins.
A nurse is assisting with the care of a hospitalized toddler who has congenital heart disease. The parent calls the nurse to the room to ask for fresh linens and states, 'My child never wets the bed at home. I am not sure why this is happening now.' Which of the following responses should the nurse make to the parent?
- A. I know this must be embarrassing for you. I have kids myself, and I would be concerned, too.
- B. Regression is a common reaction to stress when toddlers are hospitalized. This is temporary.
- C. Your child appears to be just fine. If they aren't worried about it, then you shouldn't be either.
- D. I will talk to the provider about this. It could indicate worsening of your child's condition.
Correct Answer: B
Rationale: Regression like bedwetting is common during hospitalization stress and is typically temporary. Other responses either dismiss concerns or unnecessarily escalate the issue.
A nurse is caring for an adolescent who reports manifestations of an STI. Which of the following actions should the nurse take?
- A. Request that the adolescent sign a consent for treatment form prior to performing STI screening.
- B. Instruct the adolescent that a guardian must be present to provide consent for STI screening.
- C. Plan to notify the adolescent's guardian if the STI screening comes back positive.
- D. Obtain phone consent from the guardian of the adolescent prior to performing STI screening.
Correct Answer: A
Rationale: Adolescents can consent to STI screening in many jurisdictions, respecting their privacy. Guardian involvement may deter care, and notification breaches confidentiality unless required.
A nurse is caring for an infant who has a cleft palate and is having trouble bottle feeding. Which of the following actions should the nurse take?
- A. Select a bottle with a one-way flow valve.
- B. Choose a bottle with a narrow nipple.
- C. Burp the infant every 90 ml (3 oz).
- D. Use the football hold when feeding the child.
Correct Answer: A
Rationale: A one-way flow valve bottle controls milk flow, aiding infants with cleft palate. Narrow nipples, frequent burping, or football hold are less specific to feeding challenges.
A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take?
- A. Record the diastolic value as the first Korotkoff sound (K1).
- B. Release the cuff pressure at a rate of about 5 mm Hg/second.
- C. Position the child's arm at the level of the heart.
- D. Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference.
Correct Answer: C
Rationale: Positioning the arm at heart level ensures accuracy. Diastolic is K5, cuff release should be 2-3 mm Hg/second, and cuff size is ~40% of arm circumference.