Nokea
A school nurse is assessing a school-age child’s blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first?
- A. Clear the immediate area around the child of hazardous objects
- B. loosen the child’s restrictive clothing
- C. assist the child to a side-lying position on the floor
- D. apply an oxygen mask to the child
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Mary is excited to work with the family of a friend with whom she has lost contact. Mary hopes the family will be able to connect her with her friend and is looking forward to hearing about her friend. At the next session, she asks the mother many questions about her friend and they spend a lot of time discussing their home town, etc. Which statement describes this scenario?
- A. It is not therapeutic: The relationship serves no purpose
- B. It is therapeutic: Therapist, child, and family have a reciprocal caring relationship
- C. It is not therapeutic: Mary is benefiting, but not the child and family
- D. It is therapeutic: Both parties are benefiting in the relationship
Correct Answer: C
Rationale: In this scenario, Mary's focus on her own needs and interests by asking the mother about her lost friend and hometown indicates a lack of therapeutic benefit for the child and family. Effective therapy should prioritize the needs and goals of the child and family, not the therapist's personal desires or connections. Therefore, this interaction is not therapeutic as it fails to address the primary purpose of the therapy, which is to benefit the child and family.
At a 6-month well-child checkup, a male infant is weighed. The mother asks if his weight is normal. The nurse's best response is:
- A. At 6 months, his weight should be approximately three times his birth weight.
- B. Each child grows at their own pace.
- C. At 6 months, his weight should be approximately twice his birth weight.
- D. At 6 months, a child should weigh about 10 lb more than at birth.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which assessment finding, after the dialysate is drained during peritoneal dialysis for a child experiencing acute renal failure, would warrant further action by the nurse?
- A. The dialysate is clear upon return.
- B. The volume of drained dialysate is less than the volume infused.
- C. The child is restless and eager to play.
- D. The child's vital signs remain consistent with those noted during infusion.
Correct Answer: B
Rationale: A lower volume of drained dialysate compared to the volume infused suggests a possible obstruction or malfunction in the dialysis process. This finding could compromise the effectiveness of the treatment and needs prompt assessment and intervention by the nurse to ensure the child's safety and well-being.
The nurse is expecting the admission of a child with severe isotonic dehydration. Which intravenous fluid prescription does the nurse anticipate for this child?
- A. 0.9% normal saline (NS)
- B. D5 0.2% (¼) normal saline
- C. D5W
- D. Albumin
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You are evaluating a 6-year-old male child with Langerhans cell histiocytosis (LCH); the parents state that the most common site of bone involvement is
- A. skull
- B. vertebra
- C. mandible
- D. pelvis
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.