Essential of Pediatric Nursing Test Bank

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An adolescent tells the school nurse that she is pregnant. Her last menstrual period was 4 months ago. She has not received any medical care. She smokes but denies any other substance use. What is the priority nursing action?

  • A. Notify her parents
  • B. Refer for prenatal care
  • C. Explain the importance of not smoking
  • D. Discuss dietary needs for adequate fetal growth
Correct Answer: B

Rationale: The priority nursing action in this situation is to refer the adolescent for prenatal care. Prenatal care is crucial for monitoring the health of both the mother and the baby throughout the pregnancy. This includes assessing for any potential complications, providing appropriate interventions, and ensuring proper support for a healthy pregnancy. It is important for the adolescent to receive medical care as soon as possible to optimize the outcomes for both her and her baby. While notifying her parents, explaining the importance of not smoking, and discussing dietary needs are also important aspects of care, ensuring timely access to prenatal care is the most critical priority in this scenario.

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Nursing measures in hemodynamic monitoring include assessing for localized ischemia owing to inadequate arterial flow. The nurse should:

  • A. Assess the involved extremity for color and temperature
  • B. Check for capillary refill
  • C. Evaluate pulse rate
  • D. Do all of the above
Correct Answer: D

Rationale: When assessing for localized ischemia owing to inadequate arterial flow, it is important for the nurse to perform all of the mentioned actions:

The nurse is preparing a client for magnetic resonance imaging (MRI) to confirm or rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to the client?

  • A. The client lies still.
  • B. The client wears a watch and wedding
  • C. The client asks questions. band.
  • D. the client hears thumping sounds.
Correct Answer: B

Rationale: The client wearing a watch and wedding band would pose a threat during the MRI scan. MRI machines use strong magnetic fields that can interact with metal objects. The presence of metal objects such as a watch and wedding band can lead to serious safety risks for the client inside the MRI machine. These metal objects can become projectiles or heat up, causing burns or other injuries. Thus, it is crucial for the client to remove all metal objects before undergoing an MRI scan to ensure their safety.

The laboratory results of a patient with disseminated intravascular coagulation are likely to include:

  • A. decreased levels of fibrin split products.
  • B. increased levels of fibrinogen.
  • C. increased platelet counts.
  • D. prolonged prothrombin and partial thromboplastin times.
Correct Answer: D

Rationale: DIC leads to prolonged clotting times due to consumption of clotting factors and platelets.

The nurse is talking to a parent of an infant with severe atopic dermatitis (eczema). Which response(s) should the nurse reinforce with the parent? (Select all that apply.)

  • A. "You can use warm wet compresses to relieve discomfort."
  • B. "You will need to keep your infant's skin well hydrated by using a mild soap in the bath."
  • C. "You should bathe your baby in a bubble bath two times a day."
  • D. "You will need to prevent your baby from scratching the area by using a mild antihistamine."
Correct Answer: A

Rationale: "You can use warm wet compresses to relieve discomfort." Warm wet compresses can help soothe the affected area and provide relief from itching and discomfort associated with atopic dermatitis.

HIV antibody testing procedures using a finger stick or venipuncture to obtain whole blood, plasma, or serum, and tests using oral fluid were approved. All the following regarding this test are true EXCEPT

  • A. they are simple and accurate as to render the likelihood of an erroneous result by the user negligible
  • B. a positive result does not need confirmation by Western blot analysis or immunofluorescence assay
  • C. they allow women who have not been tested or are unaware of their HIV status to reduce the risk of mother-to-child transmission of antiretroviral therapy implementation
  • D. they significantly reduce the risk of mother-to-child transmission
Correct Answer: B

Rationale: A positive result from rapid HIV tests still requires confirmation with more specific tests like Western blot or immunofluorescence assay.

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