Nokea
A school-age boy with a spinal cord injury is moved to the rehabilitation unit. The nurse notes that the child tends to refuse to cooperate in care and is quiet. The nurse interprets this behavior as indicative of which of the following?
- A. A stage of grief reaction.
- B. A phase of rebellion.
- C. A reaction to sensory overload.
- D. A response to too much attention.
Correct Answer: A
Rationale: Refusal and withdrawal are consistent with grief, reflecting the child's adjustment to significant loss of function.
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On finding a child who is not breathing, which of the following should the nurse do first?
- A. Clear the airway.
- B. Begin mouth-to-mouth resuscitation.
- C. Initiate oxygen therapy.
- D. Start chest compressions.
Correct Answer: A
Rationale: Clearing the airway is the first step in CPR to ensure no obstructions prevent effective ventilation.
A school-age child who has received burns over 60% of his body is to receive 2,000 mL of I.V. fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump?
Correct Answer: 250
Rationale: Dividing 2,000 mL by 8 hours yields 250 mL/hour. This ensures fluid resuscitation meets burn protocol (e.g., Parkland formula) to maintain hemodynamic stability.
A nurse administers ranitidine (Zantac) instead of cetirizine (Zyrtec) to an 8-year-old with asthma. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action. The charge nurse should tell the nurse:
- A. If you do not report the error, I will have to.
- B. Reporting the error helps to identify system problems to improve client safety.
- C. Notify the client's physician to see if she wants this reported.
- D. This is not a serious mistake so reporting it will not affect your position.
Correct Answer: B
Rationale: Reporting the error helps identify system problems to improve client safety, promoting a culture of transparency and quality improvement.
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 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.