Nokea
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?
- A. Limiting conversation with the child.
- B. Keeping extraneous noise to a minimum.
- C. Allowing the child to play in the bathtub.
- D. Performing treatments quickly.
Correct Answer: B
Rationale: Minimizing noise reduces sensory stimulation, which can exacerbate irritability in a child with meningitis.
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A nurse is teaching a child with a food allergy about safe eating. Which instruction is most important?
- A. Eat only home-cooked meals.
- B. Read food labels carefully.
- C. Avoid all fruits.
- D. Use herbal supplements.
Correct Answer: B
Rationale: Reading food labels prevents accidental allergen exposure. Home cooking helps but isn't always feasible, fruits are safe unless allergenic, and supplements are irrelevant.
When developing the plan of care for an infant with myelomeningocele and the parents who have just been informed of the infant's diagnosis, which action should the nurse include as the priority when the parents visit the infant for the first time?
- A. Emphasizing the infant's normal and positive features.
- B. Encouraging the parents to discuss their fears and concerns.
- C. Reinforcing the doctor's explanation of the defect.
- D. Having the parents feed their infant.
Correct Answer: A
Rationale: Highlighting normal features helps parents bond with their infant and fosters a positive perception, which is critical initially after a diagnosis.
The nurse is assessing the infant shown in the figure. On observing the infant from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani's 'click.'
- B. Limited abduction.
- C. Galeazzi's sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: Asymmetric gluteal folds are a clinical sign of developmental dysplasia of the hip, indicating possible hip dislocation or asymmetry.
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.
A mother calls the clinic to talk to the nurse. The mother states that a physician described her daughter as having 20/60 vision and she asks the nurse what this means. The nurse responds based on the interpretation that the child is experiencing which of the following?
- A. A loss of approximately one-third of her vision.
- B. Ability to see at 60 feet what she should see at 20 feet.
- C. Ability to see at 20 feet what she should see at 60 feet.
- D. Visual acuity three times better than average.
Correct Answer: C
Rationale: 20/60 vision means the child sees at 20 feet what a person with normal vision sees at 60 feet.