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After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which of the following?
- A. Inability to extend the fingers on the right hand.
- B. Vomiting after the cast is applied.
- C. Coolness and dampness of the cast after 5 hours.
- D. Fussiness with complaints that the cast is heavy.
Correct Answer: A
Rationale: Inability to extend fingers suggests possible nerve or circulatory compromise, requiring immediate medical attention.
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Which of the following meals would be most appropriate for a 15-year-old with glomerulonephritis with severe hypertension?
- A. Egg noodles, hamburger, canned peas, milk.
- B. Baked ham, baked potato, pear, canned carrots, milk.
- C. Baked chicken, rice, beans, orange juice.
- D. Hot dog on a bun, corn chips, pickle, cookie, milk.
Correct Answer: C
Rationale: Low-sodium diet is recommended.
When providing intermittent nasogastric feedings to an infant with failure to thrive, which method is preferred to confirm tube placement before each feeding?
- A. Obtain a chest X-ray.
- B. Verify that the gastric pH is less than 5.5.
- C. Auscultate the stomach while instilling an air bolus.
- D. Compare the tube insertion length to a standardized chart.
Correct Answer: B
Rationale: Gastric pH <5.5 confirms stomach placement non-invasively. X-rays are impractical for each feeding, auscultation is unreliable, and length comparison doesn't verify placement.
The parents of a 12-year-old girl ask why their non-sexually active daughter should receive the human papillomavirus (HPV) vaccine. The nurse should tell the parents:
- A. The vaccine is most effective against cervical cancer if given before becoming sexually active.
- B. Parents are never sure when their child might become sexually active.
- C. HPV is most common in teens and women in their late twenties.
- D. If your daughter is sexually assaulted, she may be exposed to HPV.
Correct Answer: A
Rationale: The HPV vaccine is most effective when given before potential exposure to the virus.
The mother of a preschooler reports that her child creates a scene every night at bedtime. The nurse and the mother decide that the best course of action would be to do which of the following?
- A. Allow the child to stay up later one or two nights a week.
- B. Establish a set bedtime and follow a routine.
- C. Encourage active play before bedtime.
- D. Give the child a cookie if bedtime is pleasant.
Correct Answer: B
Rationale: A consistent bedtime routine promotes healthy sleep habits.
While the nurse is examining the infant for presence of testes, the father paces around the room shaking his head. Which of the following would be the most appropriate response by the nurse?
- A. I'm sure everything will work out for the best
- B. and he'll be fine.
- C. You seem upset; please tell me how you're feeling.
- D. Don't worry; his testes will probably descend on their own.
- E. Would you like to talk with a parent of a child who has the same problem?
Correct Answer: B
Rationale: This response shows empathy and opens communication.