Nokea
A nurse is collecting data from an adolescent. Which of the following represents the greatest risk for suicide?
- A. Active psychiatric disorder
- B. Availability of firearms
- C. Family conflict
- D. Homosexuality
Correct Answer: A
Rationale: The presence of an active psychiatric disorder
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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.
A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?
- A. Brisk pupillary reaction to light
- B. Irritability
- C. Tachycardia
- D. Increased sensory response to painful stimuli
Correct Answer: B
Rationale: Irritability is a common early sign of increased ICP in infants. Changes in behaviour such as increased irritability or lethargy can indicate a neurological problemincluding increased pressure within the skull.
A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
- A. I will notify the doctor if his temperature is not controlled with acetaminophen.
- B. I will continue to check his blood sugar two times every day.
- C. I will report a change in breathing or signs of confusion.
- D. I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes.
Correct Answer: B
Rationale: Checking blood sugar only twice a day is insufficient during illness especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection and more frequent monitoring (at least 4 times a day or as recommended) is necessary.
A nurse in a pediatric clinic is talking with a parent of a toddler. The parent tells the nurse that her toddler drinks a quart of milk a day. The nurse should recognize that the toddler is at risk for which of the following disorders?
- A. Beriberi
- B. Dehydration
- C. Diabetes mellitus
- D. Iron-deficiency anemia
Correct Answer: D
Rationale: Excessive milk can lead to iron-deficiency anemia because milk is low in iron and can interfere with iron absorption from other foods.
A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions?
- A. Gently reinsert the tubes.
- B. Call the health care clinic to report that the tubes have fallen out.
- C. Reassure the mother that the tubes will not fall out.
- D. Take the child to an emergency department.
Correct Answer: B
Rationale: The healthcare provider needs to be informed to assess if new tubes are necessary.