Childhood schizophrenia is suggested by:
- A. Disturbance in movement patterns
- B. Persistent thumb sucking
- C. Hallucinations
- D. Infantile autism
Correct Answer: C
Rationale: Hallucinations are a key feature of childhood schizophrenia. Movement disturbances and thumb sucking are nonspecific, and infantile autism is a separate condition.
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Which medication should the nurse prepare for immediate administration to a child experiencing an anaphylactic reaction to a bee sting?
- A. Diphenhydramine (Benadryl)
- B. Dobutamine (Dobutarex)
- C. Epinephrine (Adrenalin)
- D. Calcium chloride (calcium chloride)
Correct Answer: C
Rationale: After the first priority of establishing an airway, administration of epinephrine is the drug of choice. Diphenhydramine, an antihistamine, is usually not used for severe reactions. Dobutamine and calcium chloride are not appropriate drugs for this type of reaction.
When planning care for a 8-year-old boy with Down syndrome, the nurse should:
- A. Plan interventions according to the developmental level of a 7-year-old child because that’s the child’s age
- B. Plan interventions according to the developmental levels of a 5-year-old because the child will have developmental delays
- C. Assess the child’s current developmental level and plan care accordingly
- D. Direct all teaching to the parents because the child can’t understand
Correct Answer: C
Rationale: Care should be individualized based on the child’s current developmental level, not just their chronological age or assumptions about delays.
Which comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect?
- A. He is always hungry.
- B. He tires out during feedings.
- C. He is fussy for several hours every day.
- D. He sleeps all the time.
Correct Answer: B
Rationale: Fatigue during feeding or activity is common to most infants with congenital cardiac problems.
A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse?
- A. Irregular apical pulse
- B. Purple marks on the skin of the abdomen
- C. Quarter size blood spot on dressing
- D. Pitting ankle edema
Correct Answer: A
Rationale: An irregular apical pulse could indicate cardiac complications, which are a risk in clients with Cushing's syndrome due to fluid and electrolyte imbalances.
When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, 'visual sensory/perceptual alterations.' This diagnosis is based on which etiology?
- A. Limited eye movement
- B. Decreased peripheral vision
- C. Blurred distance vision
- D. Photosensitivity
Correct Answer: B
Rationale: Open angle glaucoma primarily affects peripheral vision, leading to visual sensory/perceptual alterations.
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