Nokea
A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
- A. Low-pitched cry
- B. Positive Babinski reflex
- C. Insomnia
- D. Bulging fontanel
Correct Answer: D
Rationale: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude.
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A nurse is caring for a 4-year-old child who is postoperative following abdominal surgery. Which of the following statements should the nurse make to encourage the child to take deep breaths?
- A. This will not be painful, just a little uncomfortable.
- B. Let's play a game of blowing cotton balls across your table.
- C. Do you want to take deep breaths for me now?
- D. You can't go to the playroom until you finish doing your deep breathing.
Correct Answer: B
Rationale: This makes deep breathing fun and engaging for the child encouraging them to participate.
A nurse is providing teaching about Iron deficiency anemia to the parents of a 14-month-old. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia?
- A. Avoid a diet consisting of primarily milk.
- B. Include whole grains and legumes in the diet.
- C. Administer fat-soluble vitamins daily.
- D. Limit intake of high-protein foods.
Correct Answer: A
Rationale: Milk especially cow's milk is low in iron and can inhibit iron absorption. Excessive milk consumption can also lead to iron deficiency anemia by displacing iron-rich foods from the diet and potentially causing gastrointestinal bleeding in infants.
A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?
- A. Sweating can occur with hypoglycemia.
- B. My son might have nausea and vomiting with hypoglycemia.
- C. My son might complain of feeling shaky when he has a low blood glucose level.
- D. The onset of low blood glucose usually occurs rapidly.
Correct Answer: B
Rationale: Nausea and vomiting are typically associated with hyperglycemia and diabetic ketoacidosis (DKA) not hypoglycaemia. Hypoglycaemia usually presents with symptoms like sweating shakiness confusion and hunger.
A nurse is caring for a preschooler who has epiglottitis from a streptococcal infection. Which of the following actions should the nurse take?
- A. Attempt to obtain a throat culture.
- B. Use a tongue depressor to observe the back of the throat.
- C. Apply humidified oxygen via a mask.
- D. Initiate airborne precautions.
Correct Answer: C
Rationale: This helps to keep the airways moist and can provide some relief and improve oxygenation.
A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination?
- A. Bend forward from the waist with your head and arms downward.
- B. Lie prone on the examination table.
- C. Touch your chin to your chest, and then look up at the ceiling.
- D. Turn to the side, and remain in a relaxed position.
Correct Answer: A
Rationale: This position known as the Adam's forward bend test is commonly used to screen for scoliosis.