Nokea
A preschooler with pneumococcal meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the needle is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age-group has a need to accomplish which of the following?
- A. Trust those caring for her.
- B. Find diversional activities.
- C. Protect the image of an intact body.
- D. Relieve the anxiety of separation from home.
Correct Answer: C
Rationale: Allowing the child to apply a dressing supports their developmental need to maintain body integrity, reducing anxiety about medical procedures.
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The parent of a 9-month-old infant is concerned that the infant's front soft spot is still open. The nurse should tell the parent:
- A. I will measure your baby's head to see if it is a normal size.
- B. Your infant will need to be referred for more testing.
- C. You should contact your physician immediately.
- D. It is normal because this soft spot usually closes between 12 and 18 months.
Correct Answer: D
Rationale: The anterior fontanelle typically closes between 12-18 months, so this is normal.
To encourage autonomy in a 4-year-old, the nurse should instruct the mother to:
- A. Discourage the child's choice of clothing.
- B. Button the child's coat and blouse.
- C. Praise the child's attempts to dress herself.
- D. Tell the child when the combination of clothes is not appropriate.
Correct Answer: C
Rationale: Praising efforts fosters autonomy by encouraging independence.
When explaining to parents how to reduce the risk of Sudden Infant Death Syndrome (SIDS) the nurse should teach about which of the following measures? Select all that apply.
- A. Maintain a smoke-free environment.
- B. Use a wedge for side-lying positions.
- C. Breast-feed the baby.
- D. Place the baby on his back to sleep.
- E. Use bumper pads over
- F. Have the baby sleep in the parent's bed.
Correct Answer: A,C,D
Rationale: Maintaining a smoke-free environment, breastfeeding, and placing the baby on his back to sleep are evidence-based measures to reduce SIDS risk. Side-lying positions, bumper pads, and bed-sharing increase SIDS risk and should be avoided.
After teaching the mother of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, the mother indicates that she understands her child's prognosis when she states which of the following?
- A. My child will need to wear protective pads until puberty.
- B. My child will need extra fluids to prevent constipation.
- C. My child will probably always need a high-fiber diet.
- D. My child has a good chance of being potty trained.
Correct Answer: D
Rationale: Low anorectal anomalies often have a good prognosis for continence with proper management.
A 10-year-old has 5 lb of Buck's extension traction on his left leg. The nurse should assess the child for which of the following? Select all that apply.
- A. Dryness of the skin, by removing the foam wraps and boot.
- B. Alignment of the shoulder, hips, and knees.
- C. Frayed rope near pulleys.
- D. Correct amount of traction weight on fracture.
- E. Pressure on the coccyx.
Correct Answer: B,C,D,E
Rationale: The nurse should check alignment, rope condition, weight accuracy, and pressure points to ensure effective and safe traction.