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Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents call the development of footdrop?
- A. Apply braces to the feet and ankles.
- B. Keep the child in the side-lying position.
- C. Keep sheets tucked in at the foot of the bed.
- D. Rest the child's feet against a footboard.
Correct Answer: D
Rationale: Resting the child's feet against a footboard maintains a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
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Which finding best indicates that a school-age child has acute glomerular nephritis?
- A. Periorbital edema
- B. Excessive urination
- C. Increased appetite
- D. Low blood pressure
Correct Answer: A
Rationale: Periorbital edema is a classic sign of acute glomerular nephritis due to fluid retention from impaired glomerular filtration, reflecting reduced sodium and water excretion.
The nurse advises the parents that, to detect possible complications of juvenile rheumatoid arthritis, the child will require which periodic evaluation?
- A. Chest X-rays
- B. Dental examinations
- C. Hearing examinations
- D. Eye examinations
Correct Answer: D
Rationale: JRA can cause uveitis, an eye inflammation that may lead to vision loss if untreated. Periodic eye examinations are essential to detect this complication early.
The nurse and student nurse are caring for the postpartum client who delivered a term newborn 24 hours previously. The nurse recognizes that the student needs more information on newborn nutrition when making which statement?
- A. About half of the baby’s calorie needs are met by the fat in breast milk or formula.
- B. Lactose is the primary source of carbohydrates in breast milk and formula.
- C. Calcium supplements are not needed for the newborn regardless of the feeding method.
- D. Supplemental water should be given to all infants daily,regardless of feeding method.
Correct Answer: D
Rationale: Breast milk and formula (~90% water) meet infant water needs. Supplemental water risks hyponatremia. Fat (~50% calories) lactose and adequate calcium are correct.
The nurse is assessing the infant who may have FAS. Which findings,if observed,should the nurse associate with FAS? Select all that apply.
- A. Broad nasal bridge and flat midface
- B. Growth deficit in weight and length
- C. Excessive irritability and hypotonia
- D. Poor feeding and persistent vomiting
- E. Large jaw and overdeveloped maxilla
Correct Answer: A,B,C,D
Rationale: FAS features include broad nasal bridge flat midface growth deficits irritability hypotonia and poor feeding/vomiting due to alcohol’s effects. The jaw is small not large.
Which instruction should the nurse include when teaching the parents about the administration of oral penicillin to their child?
- A. Give the medication with a full glass of orange juice.
- B. Give the medication after a large meal.
- C. Continue the medication even if the child develops a rash.
- D. Continue the medication for the full course of therapy.
Correct Answer: D
Rationale: Completing the full course of penicillin therapy eradicates the infection and prevents recurrence or resistance, especially for streptococcal infections.