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An overweight adolescent has been diagnosed with type 2 diabetes. To increase the client's self-efficacy to manage their disease, the nurse should:
- A. Provide the client with a written daily food and exercise plan.
- B. Discuss eliminating junk food in the home with the parents.
- C. Arrange for the school nurse to weigh the child weekly.
- D. Utilize a peer with type 2 diabetes to role model lifestyle changes.
Correct Answer: D
Rationale: Peer role modeling enhances self-efficacy by providing relatable examples of successful disease management. Plans, junk food elimination, and weigh-ins are less empowering without peer support.
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Which of following should the nurse perform to help alleviate a child's joint pain associated with rheumatic fever?
- A. Maintaining the joints in an extended position.
- B. Applying gentle traction to the child's affected joints.
- C. Supporting proper alignment with rolled pillows.
- D. Using a bed cradle to avoid the weight of bed linens on joints.
Correct Answer: D
Rationale: A bed cradle reduces pressure from bed linens, alleviating joint pain in rheumatic fever. Other options may not effectively reduce pain or could cause discomfort.
Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea?
- A. Moist mucous membranes.
- B. Passage of a soft, formed stool.
- C. Absence of diarrhea for a 4-hour period.
- D. Ability to tolerate intravenous fluids well.
Correct Answer: A
Rationale: Moist mucous membranes indicate adequate hydration, the goal of treatment.
Which of the following is appropriate language development for an 8-month-old? The child should be:
- A. Saying 'dada' and 'mama' specifically ('dada' to father and 'mama' to mother).
- B. Saying three other words besides 'mama' and 'dada.'
- C. Saying 'dada' and 'mama' nonspecifically.
- D. Saying 'ball' when parents point to a ball.
Correct Answer: C
Rationale: At 8 months, infants typically say 'dada' and 'mama' nonspecifically, as specific use develops closer to 12 months.
The nurse caring for a 7 -year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. The nurse should first:
- A. Assess the vital signs.
- B. Reinforce the dressing.
- C. Apply pressure just above the catheter insertion.
- D. Notify the physician.
Correct Answer: C
Rationale: Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the physician. The dressing can be reinforced after the bleeding has been contained.
A toddler is scheduled to have tympanostomy tubes inserted. When approaching the toddler for the first time, which of the following should the nurse do?
- A. Talk to the mother first so that the toddler can get used to the new person.
- B. Hold the toddler so that the toddler becomes more comfortable.
- C. Walk over and pick the toddler up right away so that the mother can relax.
- D. Pick up the toddler and take the child to the play area so that the mother can rest.
Correct Answer: A
Rationale: Talking to the mother first allows the toddler to observe the nurse from a safe distance, helping the child become accustomed to the new person without causing immediate distress. This approach respects the toddler's developmental need for gradual introduction to strangers.