Nokea
After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to consent to the recommended vaccinations. The nurse should first ask the parent:
- A. Did you know that vaccinations are required by law for school entry?
- B. What personal beliefs or safety concerns do you have about vaccinations?
- C. Would you prefer that fewer vaccines are given at a time?
- D. Can you please sign this vaccine waiver form?
Correct Answer: B
Rationale: Addressing the parent's specific concerns fosters trust and encourages informed decision-making.
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The primary health care provider orders pulse assessments through the night for a 12-year-old child with rheumatic fever who has a daytime heart rate of 120. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by:
- A. The morning digitalis.
- B. Normal activity during waking hours.
- C. A warmer daytime environment.
- D. Normal variations in day and evening hours.
Correct Answer: B
Rationale: Elevated heart rate in rheumatic fever may be due to activity, which increases cardiac demand. Nighttime assessments help determine if the rate normalizes at rest, ruling out activity as the cause.
After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which of the following, if stated by the father, indicates successful teaching?
- A. It results from overexposure to the sun.
- B. It's caused by infestation with a mite.
- C. It's a fungal infection of the scalp.
- D. It's an allergic reaction.
Correct Answer: C
Rationale: Tinea capitis is caused by a fungal infection, not mites, sun exposure, or allergies.
Parents bring a 10-month-old boy born with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the emergency department. His symptoms include vomiting, poor feeding, lethargy, and irritability. What interventions by the nurse are appropriate? Select all that apply.
- A. Weigh the child.
- B. Listen to bowel sounds.
- C. Palpate the anterior fontanel.
- D. Obtain vital signs.
- E. Assess pitch and quality of the child's cry.
Correct Answer: C,D,E
Rationale: These symptoms suggest possible shunt malfunction or increased intracranial pressure. Palpating the anterior fontanel assesses for bulging, indicating increased pressure. Obtaining vital signs monitors for abnormalities like bradycardia or hypertension. Assessing the cry's pitch and quality can indicate neurological distress. Weighing and listening to bowel sounds are less critical in this acute context.
The nurse is assessing a child with suspected appendicitis. Which physical finding supports this diagnosis?
- A. Rebound tenderness in the right lower quadrant.
- B. Soft, non-tender abdomen.
- C. Frequent bowel movements.
- D. Generalized abdominal bloating.
Correct Answer: A
Rationale: Rebound tenderness is a key sign of appendicitis due to peritoneal irritation.
Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.