Nokea
At the 2 week well-child visit a parent states, 'My baby seems to keep his head tilted to the right.' The nurse should further assess the:
- A. Fontanel.
- B. Cervical vertebrae.
- C. Trapezius muscle.
- D. Sternocleidomastoid muscle.
Correct Answer: D
Rationale: Torticollis is commonly caused by tightness or shortening of the sternocleidomastoid muscle, which should be assessed for asymmetry or tightness.
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Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.
A preschooler with pneumococcal meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the needle is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age-group has a need to accomplish which of the following?
- A. Trust those caring for her.
- B. Find diversional activities.
- C. Protect the image of an intact body.
- D. Relieve the anxiety of separation from home.
Correct Answer: C
Rationale: Allowing the child to apply a dressing supports their developmental need to maintain body integrity, reducing anxiety about medical procedures.
Which of the following would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate (Sulfamylon)?
- A. Ensure parental support during the dressing.
- B. Allow the child to assist in removing the dressings and applying the cream.
- C. Give the child permission to cry during the procedure.
- D. Allow the child to schedule the time for dressing changes.
Correct Answer: B
Rationale: Allowing the child to participate fosters a sense of control, reducing fear and combative behavior. Parental support and crying are helpful but less empowering, and scheduling may disrupt care.
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.
When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for which of the following purposes?
- A. To decrease back muscle spasms.
- B. To improve the brace's traction effect.
- C. To prevent spinal contractures.
- D. To strengthen the back and abdominal muscles.
Correct Answer: D
Rationale: Exercises for scoliosis in a Boston brace focus on strengthening back and abdominal muscles to support spinal alignment and improve posture.