Nokea
Anticipating that a 3-year-old child in traction will have need for diversion, what should the nurse offer the child?
- A. I know game.
- B. Blocks.
- C. Hand puppets.
- D. Marbles.
Correct Answer: C
Rationale: Hand puppets are an engaging, age-appropriate diversion for a 3-year-old, promoting interaction without requiring mobility.
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The nurse is caring for a 2-year-old with iron deficiency anemia. Which laboratory finding would the nurse expect to see?
- A. Elevated hemoglobin levels.
- B. Decreased mean corpuscular volume (MCV).
- C. Increased serum ferritin levels.
- D. Elevated white blood cell count.
Correct Answer: B
Rationale: Iron deficiency anemia typically shows decreased MCV, indicating microcytic red blood cells, due to reduced iron availability for hemoglobin synthesis.
Which of the following findings should lead the nurse to decide that spinal shock was resolving in the adolescent with a spinal cord injury?
- A. Atonic urinary bladder.
- B. Flaccid paralysis.
- C. Hyperactive reflexes.
- D. Widened pulse pressure.
Correct Answer: C
Rationale: Hyperactive reflexes indicate the resolution of spinal shock, as the nervous system begins to recover from initial flaccidity.
After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child's death is imminent. Which of the following statements offers the nurse the best guide in making plans to assist the parents in dealing with their child's imminent death?
- A. Knowing that the prognosis is poor helps prepare relatives for the death of children.
- B. Relatives are especially grieved when a child does well at first but then declines rapidly.
- C. Trust in health care personnel is most often destroyed by a death that is considered untimely.
- D. It is more difficult for relatives to accept the death of an older child than that of a toddler.
Correct Answer: B
Rationale: A rapid decline after improvement is particularly devastating, guiding the nurse to provide extra emotional support.
When assessing for pain in a toddler, which of the following methods should be the most appropriate?
- A. Ask the child about the pain.
- B. Observe the child for restlessness.
- C. Use a numeric pain scale.
- D. Assess for changes in vital signs.
Correct Answer: B
Rationale: Toddlers cannot reliably verbalize pain, so observing behavior like restlessness is most appropriate.
The nurse is preparing to administer the last dose of ceftriaxone (Rocephin) before discharge to a 1-year-old but finds the I.V. has occluded. The nurse should:
- A. Restart the I.V.
- B. Administer the medication intramuscularly.
- C. Arrange for early discharge.
- D. Ask the provider to request an order change.
Correct Answer: B
Rationale: Administering ceftriaxone intramuscularly is appropriate when the I.V. is occluded, ensuring the child receives the final dose before discharge.