Nokea
Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents 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 the feet in a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.
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Which response by the nurse best explains why insulin must be given subcutaneously?
- A. The oral form of insulin can lead to the worsening of diabetes.
- B. The oral form of insulin is not yet available for use.
- C. Insulin is a protein that is destroyed by digestive enzymes.
- D. Insulin given by the oral route causes severe vomiting.
Correct Answer: C
Rationale: Insulin is a protein hormone that would be broken down by digestive enzymes in the gastrointestinal tract if taken orally, rendering it ineffective. Subcutaneous administration ensures it reaches the bloodstream intact.
The parents of the child with juvenile rheumatoid arthritis (JRA) ask the nurse why the child cannot have aspirin. The parents further explain that they have heard that aspirin is used in the elderly for arthritis and the use of the patients. The nurse correctly explains that children with JRA are given different medications than adults with arthritis and explains that the toxic effects of aspirin include which manifestations?
- A. Constipation, weight gain, and fluid retention
- B. Ringing in the ears, nausea, and vomiting
- C. Anorexia, weight loss, and double vision
- D. Headache, dry mouth, and dental cavities
Correct Answer: B
Rationale: Aspirin in children can cause toxicity, including tinnitus, nausea, and vomiting, and is avoided due to the risk of Reye's syndrome, especially in children with viral infections.
When preparing the adolescent for the examination, the nurse correctly explains that a specimen should be collected and sent to the laboratory. Which specimen should the nurse collect?
- A. Blood sample
- B. Urine sample
- C. Vaginal smear
- D. Biopsy of the cervix
Correct Answer: C
Rationale: A vaginal smear is appropriate for diagnosing gonorrhea in females, allowing culture or nucleic acid testing of cervical or vaginal secretions to detect Neisseria gonorrhoeae.
Which statement by the nurse is most therapeutic in addressing the teen's behavior?
- A. There's nothing to be scared of. This won't hurt.
- B. The stitches are strong. They won't come out.
- C. I know you're scared, but you must be brave.
- D. Let's do this later, when you're better prepared.
Correct Answer: C
Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.
A primigravida is in second stage of labour for the past two hours. Fetal head is at +1 station. Inspite of effective uterine contractions,mother is unable to push as she is exhausted. What will be the next step in her management:
- A. Wait for another one hour.
- B. Give sedation to the mother.
- C. Shift her for emergency section.
- D. Instrumental delivery.
- E. Call the anaesthetist for regional anaesthesia.
Correct Answer: D
Rationale: Instrumental delivery (e.g. forceps or vacuum) is indicated for prolonged second stage due to maternal exhaustion provided the fetal head is engaged (+1 station). Cesarean section is considered if instrumental delivery is not feasible.