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During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while the infant is held
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: Auscultating the heart and lungs while the infant is held can provide important diagnostic information in assessing the cardiac and respiratory status of the infant who had surgical correction for tetralogy of Fallot. This intervention can help the nurse identify any abnormal heart or lung sounds, which may indicate complications or issues that need further evaluation or intervention.
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A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky, and her heart feels like it is 'beating a mile a minute.' Which information is most important for the nurse to obtain?
- A. When she last took the antihistamine.
- B. When her last asthma attack occurred.
- C. Duration of most asthma attacks.
- D. How often the MDI is used daily.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a routine assessment of a 3-year-old at a community health center, the healthcare professional should be alert for signs of autism spectrum disorder. Which behavior by the child should prompt further evaluation for a possible autistic spectrum disorder?
- A. Engages in odd repetitive behaviors
- B. Shows indifference to verbal stimulation
- C. Strokes the hair of a hand-held doll
- D. Has a history of temper tantrums
Correct Answer: A
Rationale: Engaging in odd repetitive behaviors is a hallmark sign of autism spectrum disorder in children. These behaviors can include repetitive movements, insistence on sameness, or specific routines. Recognizing and addressing these behaviors early can help in providing appropriate interventions and support for the child.
The nurse is caring for a 14-year-old adolescent who was admitted to the hospital after a suicide attempt. The adolescent's mood appears stable, and the healthcare provider has recommended discharge. What is the nurse's priority action?
- A. Ensure that a safety plan is in place before discharge
- B. Provide education about medication adherence
- C. Encourage the adolescent to participate in group therapy
- D. Schedule a follow-up appointment with a mental health professional
Correct Answer: A
Rationale: The priority action for the nurse is to ensure that a safety plan is in place before discharge. A safety plan is essential to assist the adolescent in managing future crises and decreasing the likelihood of another suicide attempt. It provides guidance on coping strategies and resources to help the adolescent stay safe in times of distress.
What age-appropriate play activity should the practical nurse suggest to the parents of a 7-month-old infant to encourage visual stimulation?
- A. Play peek-a-boo.
- B. Play pat-a-cake.
- C. Imitate animal sounds.
- D. Show how to clap hands.
Correct Answer: A
Rationale: The practical nurse should suggest playing peek-a-boo to the parents of a 7-month-old infant to encourage visual stimulation. Peek-a-boo is a suitable game for this age group as it helps develop visual tracking skills and the concept of object permanence. By covering and uncovering their face or a toy, the infant learns that things still exist even when they cannot be seen, promoting cognitive development and visual engagement.
The healthcare provider is providing postoperative care to a 7-year-old child who had surgery for appendicitis. The child is experiencing pain at the surgical site. What is the healthcare provider's priority action?
- A. Administer the prescribed pain medication
- B. Encourage the child to take deep breaths
- C. Apply a warm compress to the surgical site
- D. Reposition the child to a more comfortable position
Correct Answer: A
Rationale: Administering the prescribed pain medication is crucial to effectively manage the child's postoperative pain. Pain management is a priority to ensure the child's comfort and promote healing following surgery. Encouraging deep breaths, applying warm compresses, or repositioning the child may help, but addressing the pain with medication is the initial and most vital intervention.