Nokea
During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which of the following findings should lead the nurse to formulate the nursing diagnosis Risk for infection?
- A. Dialysate leakage.
- B. Granulation tissue.
- C. Increased time for drainage.
- D. Tissue swelling.
Correct Answer: A
Rationale: Leakage increases infection risk.
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The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they state:
- A. I should call if I see changes in the color of the toes under the cast.'
- B. I should use a pillow to elevate my child's foot as he sleeps.'
- C. My baby will need a series of casts to fix her foot.'
- D. Having a cast should not prevent me from holding my baby.'
Correct Answer: B
Rationale: Using a pillow to elevate the foot may alter the cast's corrective positioning, requiring additional teaching to avoid this practice.
On the second postoperative day after repair of a cleft palate, which of the following should the nurse use to feed a toddler?
- A. Cup.
- B. Straw.
- C. Rubber-tipped syringe.
- D. Large-holed nipple.
Correct Answer: C
Rationale: A rubber-tipped syringe allows controlled feeding, minimizing stress on the surgical site while ensuring adequate nutrition.
When obtaining the nursing history from the mother of an infant with suspected intussusception, which of the following questions would be most helpful?
- A. What do the stools look like?
- B. When was the last time your child urinated?
- C. Is your child eating normally?
- D. Has your child had any episodes of vomiting?
Correct Answer: A
Rationale: Stool appearance (e.g., currant jelly stools) is a hallmark of intussusception, aiding diagnosis.
At a follow-up appointment after being hospitalized, an adolescent with a history of cystic fibrosis (CF) describes his stools to the nurse. Which of the following descriptions should the nurse interpret as indicative of continued problems with malabsorption?
- A. Soft with little odor.
- B. Large and foul-smelling.
- C. Loose with bits of food.
- D. Hard with streaks of blood.
Correct Answer: B
Rationale: Large, foul-smelling stools indicate malabsorption in cystic fibrosis, suggesting inadequate pancreatic enzyme replacement or ongoing pancreatic insufficiency.
A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to:
- A. Observe the child closely.
- B. Allow the child to participate in activities that will not tire him.
- C. Provide for adequate periods of rest between activities.
- D. Encourage someone in the family to be with the child 24 hours a day.
Correct Answer: C
Rationale: Rest is critical in rheumatic fever to reduce cardiac strain and prevent complications like carditis. Observation and limited activities are important, but rest is the priority.