Nokea
During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which of the following?
- A. Abdominal cramping.
- B. Hyperactive bowel sounds.
- C. Paralytic ileus.
- D. Profuse diarrhea.
Correct Answer: C
Rationale: Paralytic ileus is common in spinal cord injury due to autonomic disruption, necessitating abdominal assessment for bowel sounds.
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After talking with the parents of a child with Down syndrome, the nurse should help the parents establish which goal?
- A. Encouraging self-care skills in the child.
- B. Teaching the child something new each day.
- C. Encouraging more lenient behavior limits for the child.
- D. Achieving age-appropriate social skills.
Correct Answer: A
Rationale: Promoting self-care skills enhances independence and aligns with developmental goals for children with Down syndrome.
A nasogastric tube is ordered to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next?
- A. Ask for the order to be changed to oral gastric tube.
- B. Attempt to place the tube into the duodenum.
- C. Test the gastric aspirate for blood.
- D. Use extra lubrication when inserting the nasogastric tube.
Correct Answer: A
Rationale: Basilar skull fractures contraindicate NG tube insertion due to the risk of cranial penetration; an oral gastric tube is safer.
After the acute stage following an ingestion of drain cleaner by a child, the nurse should be alert for the development of which of the following as a likely complication?
- A. Tracheal stenosis.
- B. Tracheal varices.
- C. Esophageal strictures.
- D. Esophageal diverticula.
Correct Answer: C
Rationale: Corrosive ingestion can scar the esophagus, leading to strictures. Tracheal complications are less common unless the airway is directly affected, and diverticula are not typical.
Which of the following questions should the nurse ask first when obtaining a history from the mother of a 10-year-old child with a fever, complaints of not feeling well, and swelling around the eyes?
- A. Has the child had a sore throat recently?
- B. Is the child playing with friends as usual?
- C. Does the child urinate as much as usual?
- D. Is the urine pale in color?
Correct Answer: A
Rationale: Sore throat could indicate streptococcal infection.
Which of the following foods should the nurse encourage the mother to offer to her child with iron deficiency anemia?
- A. Rice cereal, whole milk, and yellow vegetables.
- B. Potato, peas, and chicken.
- C. Macaroni, cheese, and ham.
- D. Pudding, green vegetables, and rice.
Correct Answer: B
Rationale: Chicken and peas are iron-rich, supporting anemia treatment. Other options lack sufficient iron sources.