Nokea
After teaching the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home, the nurse determines that the teaching has been successful when the parent states which of the following?
- A. We will keep the restraints on continuously except when checking the skin under them for redness.
- B. We will keep the restraints on during the day while he is awake, but take them off when we put him to bed at night.
- C. After we get home, we won't have to use the restraints because our child does not suck on his thumb.
- D. We will be sure to keep the restraints on all the time until we come to see the physician for a follow-up visit.
Correct Answer: A
Rationale: Elbow restraints should be worn continuously but removed periodically to check for skin irritation, ensuring both safety and comfort.
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A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:
- A. Place a pillow under the child's buttocks to provide support.
- B. Remove the weight from the left leg.
- C. Assess the feet for signs of neurovascular impairment.
- D. Reposition the pulleys so the traction is looser.
Correct Answer: C
Rationale: Assessing for neurovascular impairment is critical, as pain could indicate compromised circulation or nerve function.
A child with celiac disease is at risk for which complication if the diet is not followed?
- A. Renal failure.
- B. Intestinal lymphoma.
- C. Pulmonary fibrosis.
- D. Cardiomyopathy.
Correct Answer: B
Rationale: Untreated celiac disease increases the risk of intestinal lymphoma due to chronic inflammation. Renal, pulmonary, or cardiac complications are not directly associated.
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.
When discussing the onset of adolescence with parents, the nurse explains that it occurs at which of the following times?
- A. Same age for both boys and girls.
- B. 1 to 2 years earlier in boys than in girls.
- C. 1 to 2 years earlier in girls than in boys.
- D. 3 to 4 years later in boys than in girls.
Correct Answer: C
Rationale: Girls typically enter puberty 1-2 years earlier than boys, around ages 10-12.
After teaching the parents of a child with febrile seizures about methods to lower temperature other than using medication, which of the following statements indicates that further teaching is necessary?
- A. We'll add extra blankets when he complains of being cold.'
- B. We'll wrap him in a blanket if he starts shivering.'
- C. We'll make the bath water cold enough to make him shiver.'
- D. We'll use a solution of half alcohol and half water when sponging him.'
Correct Answer: A,B,C,D
Rationale: All options are incorrect: blankets increase temperature, cold baths cause discomfort, and alcohol sponging is unsafe. Further teaching is needed.