Nokea
A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
- A. Insomnia
- B. Irritability
- C. Diarrhea
- D. Hypothermia
Correct Answer: B
Rationale: Irritability may signal increased intracranial pressure post-head injury, requiring prompt reporting. Insomnia, diarrhea, and hypothermia are less directly related.
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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 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- C. The parent is withdrawn and rarely interacts with the child.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Rationale: A withdrawn parent suggests emotional distress or difficulty coping, indicating a need for support.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.
A nurse is assisting with the care of a hospitalized toddler who has congenital heart disease. The parent calls the nurse to the room to ask for fresh linens and states, 'My child never wets the bed at home. I am not sure why this is happening now.' Which of the following responses should the nurse make to the parent?
- A. I know this must be embarrassing for you. I have kids myself, and I would be concerned, too.
- B. Regression is a common reaction to stress when toddlers are hospitalized. This is temporary.
- C. Your child appears to be just fine. If they aren't worried about it, then you shouldn't be either.
- D. I will talk to the provider about this. It could indicate worsening of your child's condition.
Correct Answer: B
Rationale: Regression like bedwetting is common during hospitalization stress and is typically temporary. Other responses either dismiss concerns or unnecessarily escalate the issue.
A nurse is contributing to a plan of care for a 24-month-old toddler. Which of the following actions should the nurse take?
- A. Allowing the toddler to button up their own shirt
- B. Asking the toddler questions that have 'yes' or 'no' answers
- C. Providing the toddler with opportunities to share toys with others
- D. Making sure the toddler has at least one nap during the day
Correct Answer: D
Rationale: Ensuring a nap supports rest and development. Buttoning shirts, yes/no questions, and sharing toys are beneficial but not the priority over rest for a toddler's well-being.
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.