Nokea
An 11-year-old is admitted for treatment of an asthma attack. Which of the following indicates immediate intervention is needed?
- A. Thin, copious mucous secretions.
- B. Productive cough.
- C. Intercostal retractions.
- D. Respiratory rate of 20 breaths/minute.
Correct Answer: C
Rationale: Intercostal retractions indicate significant respiratory distress in an asthma attack, as they reflect increased effort to breathe due to airway obstruction. This requires immediate intervention to prevent further deterioration.
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Which of the following would be most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with severe diarrhea to help her comfort her infant who is fussy?
- A. Offering a pacifier.
- B. Placing a mobile above the crib.
- C. Sitting at crib side talking to the infant.
- D. Turning the television on to cartoons.
Correct Answer: A
Rationale: A pacifier provides non-nutritive sucking, soothing a fussy infant.
When assessing an infant with suspected inguinal hernia, which of the following findings would be most significant?
- A. The inguinal swelling is reddened, and the abdomen is distended.
- B. The infant is irritable, and a thickened spermatic cord is palpable.
- C. The inguinal swelling can be reduced, and the infant has a stool in the diaper.
- D. The infant's diaper is wet with urine, and the abdomen is nontender.
Correct Answer: B
Rationale: Irritability and a thickened spermatic cord suggest a hernia, indicating possible incarceration.
An adolescent tells the school nurse that she would like to use tampons during her period. The nurse should first:
- A. Assess her usual menstrual flow pattern.
- B. Determine whether she is sexually active.
- C. Provide information about preventing toxic shock syndrome.
- D. Refer her to a specialist in adolescent gynecology.
Correct Answer: C
Rationale: Educating about toxic shock syndrome is critical due to the risk associated with tampon use.
A parent of a child with a moderate head injury asks the nurse, 'How will you know if my child is getting worse?' The nurse should tell the parents that the best indicator of the child's brain function is:
- A. The vital signs.
- B. Level of consciousness.
- C. Reactions of the pupils.
- D. Motor strength.
Correct Answer: B
Rationale: Level of consciousness is the most sensitive indicator of brain function, reflecting changes in neurological status.
An 8-year-old with diabetes is placed on neutral and immune Hagedorn (NPH) and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. The snack will:
- A. Help her regain lost weight.
- B. Provide carbohydrates for immediate use.
- C. Prevent late night hypoglycemia.
- D. Help her stay on her diet.
Correct Answer: C
Rationale: A bedtime snack with NPH insulin prevents late-night hypoglycemia by providing carbohydrates during peak insulin action. It is not primarily for weight gain, immediate use, or diet adherence.