Nokea
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- C. The parent is withdrawn and rarely interacts with the child.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Rationale: A withdrawn parent suggests emotional distress or difficulty coping, indicating a need for support.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.
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A nurse is reinforcing teaching with a school-age child who has mild persistent asthma and has a new prescription for therapy with montelukast. Which of the following information should the nurse include?
- A. This medication helps prevent bronchospasms.
- B. This medication is a corticosteroid.
- C. You should take this medication for an acute asthma attack.
- D. You should take this medication first thing in the morning.
Correct Answer: A
Rationale: Montelukast prevents bronchospasms by reducing airway inflammation. It is not a corticosteroid, not for acute attacks, and is typically taken in the evening.
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 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.
A nurse is reinforcing teaching about introducing solid foods with the parents of a 6-month old infant who is bottle-fed. Which of the following information should the nurse include?
- A. You should use canned fruits and vegetables to introduce your baby to solid foods.
- B. You should introduce one new food to your baby every 5 to 7 days.
- C. You should introduce a new food by giving your baby 3 to 4 tablespoons.
- D. You should add rice cereal to a bottle before introducing your baby to solid foods.
Correct Answer: B
Rationale: Introducing one food every 5-7 days helps identify allergies. Fresh foods are preferred, initial amounts are smaller, and cereal in bottles risks choking.
A nurse is collecting data from a 5-month-old infant who is postoperative following umbilical hernia repair. Which of the following measures should the nurse use to evaluate the infant's pain level?
- A. FLACC pain rating scale
- B. COMFORT pain rating scale
- C. FACES pain rating scale
- D. CRIES pain rating scale
Correct Answer: A
Rationale: FLACC is ideal for non-verbal infants post-surgery. COMFORT suits ICU settings, FACES is for older children, and CRIES is for neonates up to 6 months.