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A nurse is caring for a 4-year-old child who has pneumonia due to varicella zoster. The parent asks the nurse what types of activities are available for the child. Which of the following play activities should the nurse recommend?
- A. Watching cartoons in the unit activity room with peers
- B. Pulling a wagon of stuffed animals in the hallway
- C. Writing a short letter to send to a friend
- D. Playing an alphabet flash card game with the parent
Correct Answer: D
Rationale: Alphabet flashcards are safe, low-exertion, and avoid infection spread. Cartoons with peers, wagon pulling, or writing are riskier or too demanding.
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A nurse is making a home visit to a 5-year-old child who has cerebral palsy and uses a wheelchair. Which of the following observations made by the nurse indicates that the family needs support and resources to cope with the child's condition?
- A. A grandparent is assisting the child in performing ADLs.
- B. The child is playing a game with their siblings.
- C. The parent is withdrawn and rarely interacts with the child.
- D. The step-parent is helping the child prepare to transition into school.
Correct Answer: C
Rationale: A withdrawn parent suggests emotional distress or difficulty coping, indicating a need for support. Grandparent assistance, sibling play, and step-parent involvement reflect positive family engagement.
A nurse is collecting data from an 8-month-old infant. Which of the following findings indicates expected growth and development?
- A. Inability to hold a bottle
- B. Uses palmar grasp
- C. Sits unsupported
- D. Forces tongue outward when it is touched
Correct Answer: C
Rationale: Sitting unsupported by 8 months is expected. Bottle holding occurs earlier, palmar grasp fades by this age, and tongue thrust typically resolves by 6 months.
A nurse is reinforcing teaching with an adolescent client who has a prescription for lisinopril. Which of the following foods should the nurse instruct the client to avoid?
- A. Foods high in fiber
- B. High-potassium foods
- C. Foods high in vitamin K
- D. Dairy products
Correct Answer: B
Rationale: Lisinopril can raise potassium levels, so avoiding high-potassium foods prevents hyperkalemia. Fiber, vitamin K, and dairy are not contraindicated.
A nurse is caring for a preschooler who has diabetes mellitus and is pale, diaphoretic, and irritable. The child's blood glucose level is 52 mg/dL. Which of the following actions should the nurse take first?
- A. Give 1 tsp of peanut butter to the child.
- B. Recheck the child's blood glucose level.
- C. Administer 1 tbsp of sugar to the child.
- D. Document the incident in the child's record.
Correct Answer: C
Rationale: Administering sugar treats hypoglycemia quickly in a conscious child. Peanut butter is slow-acting, rechecking delays treatment, and documentation follows intervention.
A nurse in a clinic is caring for a group of infants. Which of the following findings should the nurse report as a possible indication of physical maltreatment?
- A. A hemangioma on the infant's torso
- B. A burn with splash marks on the lower right leg
- C. A large, irregular, brownish-blue area on the infant's buttock
- D. An abrasion on the back of the infant's arm
Correct Answer: B
Rationale: Splash-mark burns suggest possible abuse due to their pattern and should be reported. Hemangiomas are benign, bruises need context, and abrasions may be accidental.