Nokea
A nurse is talking with a 13-year-old female client who is having her annual health-screening visit. Which of the following comments by the client should concern the nurse?
- A. My parents treat me like a baby sometimes.
- B. There's a pimple on my face, and I worry that everyone will notice it.
- C. I start taking ibuprofen a few days before my period starts.
- D. None of the kids at my school like me, and I don't like them either.
Correct Answer: D
Rationale: This statement indicates social isolation and potential issues with peer relationships which can be a red flag for emotional distress or depression.
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A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?
- A. Capillary refill less than 2 seconds
- B. Tingling in the right foot
- C. 2+ right pedal pulse
- D. Respiratory rate 24/min
Correct Answer: B
Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
- A. Low-pitched cry
- B. Positive Babinski reflex
- C. Insomnia
- D. Bulging fontanel
Correct Answer: D
Rationale: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude.
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Restrain the child's arms.
- B. Insert a padded tongue blade into the child's mouth.
- C. Place the child in a side-lying position.
- D. Elevate the child's legs on a pillow.
Correct Answer: C
Rationale: This helps maintain an open airway and allows for drainage of saliva or vomit reducing the risk of aspiration.
A nurse is reinforcing teaching with an assistive personnel (AP) about counting the respiratory rate for a 1-month-old infant. Which of the following statements by the AP indicates an understanding of the teaching?
- A. I will immediately report irregular respirations.
- B. I will immediately report a respiratory rate of 28.
- C. I will count the baby's respirations for 30 seconds and multiply by two.
- D. I will count the baby's respirations by observing abdominal movements.
Correct Answer: D
Rationale: In infants respiration is primarily diaphragmatic making abdominal movements a reliable indicator of respiratory rate.
A nurse is preparing to administer acetaminophen 15 mg/kg PO to a preschool child for fever. The child weighs 30 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 6.4 mL
- B. 5.4 mL
- C. 7.4 mL
- D. 4.4 mL
Correct Answer: 6.4
Rationale: Calculation: 30 lb × 0.454 kg/lb = 13.62 kg; 15 mg/kg × 13.62 kg = 204.3 mg; 204.3 mg ÷ 160 mg/5 mL = 6.4 mL.