Nokea
A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?
- A. A school-age child who cries when the nurse is giving him an injection
- B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy
- C. A preschooler who has a BMI indicating obesity
- D. An adolescent who asks to stay in the hospital because he likes the room
Correct Answer: D
Rationale: This might indicate that the adolescent is not feeling safe or comfortable at home which could be a sign of abuse or neglect.
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A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Cyanosis with crying
- B. Weak pulses
- C. Chronic hypoxemia
- D. Machine-like murmur
Correct Answer: D
Rationale: A characteristic feature of PDA is a continuous
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 caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?
- A. My baby's fingers are looking swollen.
- B. The tape is coming off the IV needle.
- C. There's blood backing up my baby's IV tubing.
- D. There's a long red streak up my baby's arm.
Correct Answer: A
Rationale: Swelling around the IV site can indicate infiltration where IV fluids leak into surrounding tissues.
A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks?
- A. Defining a sense of self
- B. Learning to perform tasks independently
- C. Learning to use creative energies
- D. Building a sense of trust
Correct Answer: A
Rationale: Adolescence is characterized by the search for identity and defining a sense of self. Erikson identifies this stage as "Identity vs. Role Confusion where individuals explore and form their own identity separate from their family and childhood roles.
A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?
- A. Firmly push a cotton ball into the ear canal after instilling drops.
- B. Pull the child's ear auricle upward and outward just before instilling drops.
- C. Apply clean gloves and clean the outer ear prior to instilling drops.
- D. Warm the medication container for 10 seconds in a microwave oven prior to installation.
Correct Answer: C
Rationale: Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.