Nokea
A parent of a child with a moderate head injury asks the nurse, 'How will you know if my child is getting worse?' The nurse should tell the parents that the best indicator of the child's brain function is:
- A. The vital signs.
- B. Level of consciousness.
- C. Reactions of the pupils.
- D. Motor strength.
Correct Answer: B
Rationale: Level of consciousness is the most sensitive indicator of brain function, reflecting changes in neurological status.
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The family of a 5-year-old, only child has just moved to a rural setting where the father has started a dental practice. At the well-child visit, the father expresses concern that his child seems prone to minor accidents such as skinning his elbow and knees or falling off his scooter. The nurse tells the father:
- A. Only children use accidents as a way to seek parents' attention.
- B. Children who live in the suburbs typically have more accidents.
- C. Children frequently have more accidents when families experience change.
- D. We see a relationship between accidents and parental education.
Correct Answer: C
Rationale: Changes like moving can increase accidents due to stress or unfamiliar environments.
An adolescent with a history of surgical repair for an undescended testis comes to the clinic for a sports physical. Anticipatory guidance for the parents and adolescent should focus on which of the following as most important?
- A. The adolescent's sterility.
- B. The adolescent's future plans.
- C. Technique for monthly testicular self-examinations.
- D. Need for a lot of psychological support.
Correct Answer: C
Rationale: Monthly self-exams help detect issues early.
The nurse is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect. The nurse verifies the child's identity by checking the arm band and:
- A. Asking the child to state her name.
- B. Checking the room number.
- C. Asking the child to tell her birth date.
- D. Asking the parent the child's name.
Correct Answer: D
Rationale: Asking the parent is appropriate for a 3-year-old, who may not reliably state their name or birth date. Room numbers are not reliable identifiers.
A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate positive attachment behaviors upon discharge. Which intervention would be least effective in accomplishing this goal?
- A. Provide opportunities for the mother to hold and examine the newborn.
- B. Engage the mother in the newborn's care.
- C. Create an environment that fosters privacy for the mother and newborn.
- D. Identify strategies to prevent difficulties in parenting.
Correct Answer: D
Rationale: Preventing parenting difficulties is less directly related to fostering immediate attachment.
The parents of a child who requires skeletal traction are unable to visit their child for more than one hour a day because of their jobs. The nurse should:
- A. Encourage the parents to spend more time with the child.
- B. Arrange for volunteers or staff to provide companionship.
- C. Suggest the parents adjust their work schedules.
- D. Provide the child with a phone to contact the parents.
Correct Answer: B
Rationale: Arranging companionship helps meet the child's emotional needs when parents are unavailable due to work constraints.