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A nurse is collecting data from a child who recently experienced a psychomotor seizure. Which of the following findings should the nurse expect?
- A. Hyperactivity
- B. Nystagmus
- C. Apnea
- D. Amnesia
Correct Answer: D
Rationale: Amnesia is common post-psychomotor seizure. Hyperactivity, nystagmus, or apnea are not typical postictal findings.
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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 in a provider's office is collecting data from an adolescent who has juvenile idiopathic arthritis and has been taking ibuprofen daily for the last 6 months. Which of the following client statements should the nurse report to the provider?
- A. I have morning stiffness in my joints.
- B. I have been taking a multivitamin that contains iron.
- C. I noticed some blood in my stool this morning.
- D. I skipped taking my ibuprofen last week after I went swimming.
Correct Answer: C
Rationale: Blood in stool suggests possible GI bleeding from long-term ibuprofen use, requiring urgent reporting. Stiffness is expected, vitamins are benign, and a single missed dose is less critical.
A nurse in a pediatric unit is assisting with providing care for multiple children. Which of the following physical findings and parental reports should cause the nurse to suspect child maltreatment?
- A. A toddler has a spiral fracture, and the parent reports a fall from a swing.
- B. A preschooler has bruises on the shins, and the parent reports a collision with furniture.
- C. An adolescent has a head injury, and the parent reports a fall from a bike.
- D. A school-age child has a black eye, and the parent reports a fight with a classmate.
Correct Answer: A
Rationale: Spiral fractures in toddlers are concerning for abuse, as they often result from twisting forces not typical in a fall from a swing. Bruises on shins, head injuries from biking, and a black eye from a fight are more consistent with common childhood injuries.
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 contributing to the plan of care for a child who has nephrotic syndrome and a prescription for corticosteroids. Which of the following interventions should the nurse recommend?
- A. Provide a low-sodium diet.
- B. Encourage increased fluid intake.
- C. Obtain urine ketone levels weekly.
- D. Administer pancreatic enzymes with each meal.
Correct Answer: A
Rationale: A low-sodium diet manages fluid retention in nephrotic syndrome. Increased fluids worsen edema, urine ketones are irrelevant, and pancreatic enzymes are not indicated.