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A nurse is providing care for a toddler diagnosed with autism spectrum disorder and failure to thrive. What strategy should the nurse employ?
- A. Propose food even if the child shows no interest.
- B. Integrate play activities during meal times.
- C. Establish regular meal times.
- D. Permit a variety of food options.
Correct Answer: C
Rationale: Regular meal times provide structure, aiding nutrition in autism spectrum disorder.
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An adolescent client reports to the nurse of walking with a limp due to pain localized in the right knee which worsens at night but denies any recent injury or trauma. The nurse observes swelling and tenderness in the right lower thigh and imaging results reveal radial ossification in the soft tissues. What condition should the nurse consider as the probable cause of the findings?
- A. Osteosarcoma
- B. Hemosiderosis
- C. Growing pains
- D. Rhabdomyolysis
Correct Answer: A
Rationale: Symptoms and radial ossification suggest osteosarcoma, a common bone tumor in adolescents.
A 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?
- A. Stool containing mucus and blood.
- B. An olive-sized mass in the epigastric region.
- C. Frequent burping accompanied by poor feeding.
- D. Rebound tenderness in the left lower abdominal quadrant.
Correct Answer: B
Rationale: An olive-sized mass suggests pyloric stenosis, a common cause of projectile vomiting.
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Place a toy in the child's hands while listening to the breath sounds.
- B. Allow the child to use a stethoscope on a stuffed animal.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Have the child blow a cotton ball and have the parent catch it.
Correct Answer: B
Rationale: Using a stethoscope on a stuffed animal engages the child, reducing fear and improving cooperation.
The nurse is monitoring a child with hydrocephalus who received a ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement
- B. The child reports no evidence of continuous headaches
- C. An intracranial pressure (ICP) monitoring probe is in place
- D. The child is afebrile with normal vital signs postoperatively.
Correct Answer: B
Rationale: Absence of continuous headaches indicates the shunt is relieving brain pressure effectively.
A mother brings her 2-month-old to the well-baby clinic. She mentions that when she kisses her baby, the infant's skin tastes salty. What standard diagnostic test should the nurse prepare the mother for to screen for cystic fibrosis (CF)?
- A. Fecal-fat test.
- B. Sweat-chloride test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: B
Rationale: The sweat-chloride test is the standard diagnostic for cystic fibrosis, detecting elevated chloride levels.