Nokea
During a physical assessment of a hospitalized 5-year-old child, the nurse notes that the foreskin has been retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis. What action should the nurse implement?
- A. Forcibly push the foreskin down over the head of the penis.
- B. Place a warm compress on the penis.
- C. Notify the charge nurse.
- D. Wait a few hours and try again.
Correct Answer: C
Rationale: Notify the charge nurse of this occurrence of paraphimosis. The tight foreskin can impede blood flow to the penis; this should be remedied immediately.
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The nurse discussed strategies with a parent to prevent a recurrence of urinary tract infection in the child. Which statement made by the parent indicates a need for further teaching?
- A. My daughter should wash and wipe the perineal area from front to back.'
- B. I am only going to have my daughter wear cotton underwear.'
- C. It is acceptable to take frequent bubble baths.'
- D. She needs to drink lots of fluids and void frequently.'
Correct Answer: C
Rationale: Oils in bubble bath and similar products are known to irritate the urethra.
Diuresis has not occurred on a child with nephrotic syndrome after a month on corticosteroids. What protocol can the nurse encourage to bring about diuresis?
- A. Ibuprofen, an anti-inflammatory agent
- B. Furosemide (Lasix), a diuretic
- C. Ciprofloxacin (Cipro), an antibiotic
- D. Cyclophosphamide (Cytoxan), an antisuppressant
Correct Answer: D
Rationale: A potent antisuppressant such as Cytoxan can bring about diuresis when corticosteroids have proven ineffective.
Which statement made by a parent of a child with nephrotic syndrome indicates an understanding of discharge teaching?
- A. I will make sure he gets his measles vaccine as soon as he gets home.'
- B. He can stop taking his medication next week.'
- C. I should check his urine for protein when he goes to the bathroom.'
- D. He should eat a low-protein diet for the next few weeks.'
Correct Answer: C
Rationale: The parents should be instructed to keep a daily record of the child's urinary proteins.
The nurse explains the medically accepted definition of constipation is fewer than bowel movements in a 2-week period.
Correct Answer: 7
Rationale: The medically accepted definition of constipation is fewer than seven bowel movements in a 2-week period.
What will the nurse caring for a newborn with exstrophy of the bladder include in the care? (Select all that apply.)
- A. Diaper infant tightly.
- B. Protect skin around bladder.
- C. Position infant on back.
- D. Prepare for surgical closure.
- E. Cover exposed bladder with shield.
Correct Answer: B,C,D,E
Rationale: The infant is kept on his back or side with special attention to the skin around the exposed bladder, which is constantly bathed with urine.