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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.
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A nurse is reinforcing teaching with the parents of a preschooler who has recently started to stutter. Which of the following instructions should the nurse include?
- A. Critique your child's speech.
- B. Look away from your child when they start to stutter.
- C. Avoid completing your child's sentences.
- D. Tell your child to take a deep breath when they are stuttering.
Correct Answer: C
Rationale: Avoiding sentence completion reduces pressure and supports fluency. Critiquing, looking away, or suggesting deep breaths may increase anxiety and worsen stuttering.
A nurse is collecting data from a toddler who has heart failure. Which of the following findings should the nurse expect?
- A. Weight loss of 0.9 kg (2 lb)
- B. Heart rate 65/min
- C. Bounding peripheral pulses
- D. Decreased urine output
Correct Answer: D
Rationale: Decreased urine output is expected in heart failure due to poor renal perfusion. Weight gain, not loss, is typical, and heart rate is usually elevated, not normal. Pulses are often weak.
A nurse is reinforcing car seat safety instructions with the parents of a 15-month-old toddler. Which of the following statements by the parents indicates an understanding of the teaching?
- A. I should place my child in a forward-facing car seat to ensure safety.
- B. I should place my child in the front seat in a rear-facing car seat.
- C. I should continue to use a booster seat until my child is 5 years old.
- D. I should place my child in a rear-facing car seat until age 2.
Correct Answer: D
Rationale: Rear-facing car seats until age 2 protect the child's head, neck, and spine. Forward-facing too early, front-seat placement, or premature booster use increase injury risk.
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 caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority?
- A. Monitor capillary refill of the casted extremity.
- B. Use the palms of the hands when supporting the cast.
- C. Examine the skin at the cast edges.
- D. Instruct the child not to put anything inside the cast.
Correct Answer: A
Rationale: Monitoring capillary refill is critical to assess circulation and detect complications like compartment syndrome post-cast application. Supporting the cast, checking skin, and instructing the child are important but secondary to ensuring circulation.