Nokea
A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10.
- A. "Continue with the pain assessment."'
- B. "Take the child's vital signs."'
- C. "Notify the primary care provider."'
- D. "Auscultate the child's bowel sounds."'
Correct Answer: C
Rationale: The correct answer is C, "Notify the primary care provider." This is because a pain rating of 8 in a child with appendicitis indicates severe pain that may require immediate medical intervention. The primary care provider should be informed promptly to assess the situation and determine the appropriate course of action, which may include pain management or surgical intervention. Taking vital signs (choice B) and auscultating bowel sounds (choice D) are important assessments but do not address the urgency of the situation. Continuing with the pain assessment (choice A) may delay necessary interventions.
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A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning in preschoolers. Which of the following should the nurse include?
- A. Have syrup of ipecac available in the home.
- B. Explain to preschool children that plants can be eaten only after they are cooked.
- C. Keep labels on containers of toxic substances and never remove them.
- D. Place medications in a cabinet above the sink.
Correct Answer: C
Rationale: The correct answer is C: Keep labels on containers of toxic substances and never remove them. This is important to prevent accidental poisoning in preschoolers as it helps parents and caregivers easily identify and differentiate toxic substances from safe ones. Removing labels can lead to confusion and increase the risk of accidental ingestion. Having syrup of ipecac available (choice A) is no longer recommended as a first-aid treatment for poisoning. Teaching children to cook plants before eating them (choice B) is not a practical or safe approach. Placing medications in a cabinet above the sink (choice D) may not be effective as preschoolers can still access them if the cabinet is not securely locked.
A 38 week gestation newborn weighs 4020 grams, is sluggish, and has limp muscle tone. The baby experienced a broken clavicle during delivery. Based on this information, which can the nurse conclude about the baby?
- A. Neonatal abstinence symptoms
- B. Large for gestational age
- C. Congenital cardiac defect
- D. Respiratory depression
Correct Answer: B
Rationale: The correct answer is B: Large for gestational age. A newborn weighing 4020 grams at 38 weeks is considered large for gestational age. The sluggishness and limp muscle tone can be attributed to the baby's size, which can make movement more challenging. The broken clavicle could have occurred during delivery due to the baby's size and the forces involved. Neonatal abstinence symptoms (choice A) typically present with irritability, tremors, and poor feeding, not sluggishness. Congenital cardiac defects (choice C) usually manifest with cyanosis, tachypnea, and poor feeding. Respiratory depression (choice D) is characterized by poor respiratory effort, not sluggishness and limp muscle tone.
Which of the following emotional manifestations demonstrates an improvement in a 7-month-old infant diagnosed with nonorganic failure to thrive?
- A. Infant has no fear of strangers.
- B. Infant scans environment with wide-eyed gaze.
- C. Infant is passive and sleeps well.
- D. Infant likes to be held and touched.
Correct Answer: D
Rationale: The correct answer is D: Infant likes to be held and touched. This demonstrates an improvement in the infant's emotional well-being as it shows an attachment behavior, indicating a sense of security and trust. Infants with nonorganic failure to thrive often exhibit social withdrawal and disinterest in physical contact. Choice A is incorrect as it describes a lack of stranger anxiety, which is not necessarily indicative of improvement in this context. Choice B is incorrect as a wide-eyed gaze could indicate vigilance or anxiety rather than positive emotional development. Choice C is incorrect as passivity and good sleep are not specific indicators of emotional improvement. In summary, choice D is the correct answer as it reflects positive emotional progress in the infant's attachment and responsiveness to touch.
Which is the recommended treatment for moderate to severe lead poisoning?
- A. IV fluids
- B. Antiemetics
- C. Heavy metal antagonist
- D. Antibiotics
Correct Answer: C
Rationale: The heavy metal antagonist, edetate calcium disodium, is frequently the drug of choice for the removal of the lead toxin from the body. Chelating agents inactivate the toxicity of the lead and cause excretion through the urine. IV fluids, antiemetics, and antibiotics do not address the core issue of removing lead from the body.
An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism?
- A. Rubella
- B. Gonorrhea
- C. Syphilis
- D. Human immunodeficiency virus (HIV)
Correct Answer: B
Rationale: The correct answer is B: Gonorrhea. Erythromycin ointment is used to prevent ophthalmia neonatorum, a purulent conjunctivitis that can result from gonorrhea infection in newborns during passage through the birth canal. Gonorrhea is a common cause of this condition, and timely administration of erythromycin helps prevent its development. Rubella, syphilis, and HIV do not typically cause ophthalmia neonatorum, so choices A, C, and D are incorrect in this context.