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If the physician orders a magnetic resonance imaging (MRI) study for the child with a brain tumor, which statement by the nurse would best prepare the child for the diagnostic test?
- A. MRI machines differ with some being tunnel-like and others open.
- B. Pain may occur when the dye is injected into the vein.
- C. You'll be given medicine that will make you sleep during the test.
- D. You'll have little electrodes placed on your head with a special gel.
Correct Answer: A
Rationale: Explaining that MRI machines vary (tunnel-like or open) prepares the child for the procedure by addressing potential fears about the machine's appearance, ensuring they know what to expect.
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Which clinical manifestation of the client's full-thickness burns would the nurse detect during an assessment?
- A. Moderate level of pain due to exposed nerve endings
- B. Eschar formation throughout the area of the burn
- C. The appearance of blister formation throughout the area of the burn
- D. Noted tissue destruction extending to the subcutaneous layer
Correct Answer: D
Rationale: Full-thickness burns involve destruction of all skin layers, including the subcutaneous layer, resulting in a leathery or charred appearance. Pain is minimal due to nerve destruction, and blisters are characteristic of partial-thickness burns.
Which explanation by the nurse is most accurate?
- A. Your child's condition, which involves a 35-degree curvature, may improve without treatment.
- B. Your child may develop problems with bladder control without treatment.
- C. Your child may develop problems with bowel control without treatment.
- D. Your child may develop breathing problems without treatment.
Correct Answer: D
Rationale: A 35-degree scoliosis curvature is significant and, without treatment, may progress, potentially compressing the lungs and causing breathing difficulties.
The nurse completes teaching in preparation to discharge a mother and her 48-hour-old,full-term newborn. The nurse determines there is a need for further instruction about infant car safety when the newborn’s father is overheard making which statement?
- A. “We need to face the infant car seat toward the back of the car.”
- B. “I disarmed one front seat air bag so we can put the car seat in the front seat.”
- C. “Let’s check the car seat to make sure it will position the baby at a 45-degree angle.”
- D. “I know the baby will need to be in the infant car seat until he is over 20 pounds.”
Correct Answer: B
Rationale: The rear seat is safest for infants; air bags should not be disarmed for front-seat placement. Rear-facing 45-degree angle and car seat use until 20 lb are correct.
The nurse would be correct to set the infusion pump for which hourly rate?
- A. 50 mL
- B. 75 mL
- C. 100 mL
- D. 125 mL
Correct Answer: D
Rationale: The order is 1,000 mL over 8 hours. Dividing 1,000 by 8 gives 125 mL/hour, the correct rate for the infusion pump.
Which of the following assessment findings would alert the nurse that the child may be exhibiting early signs of sepsis?
- A. Increased level of pain
- B. Disorientation
- C. Decreased urine output
- D. Jitteriness
Correct Answer: B
Rationale: Disorientation can indicate early sepsis in burn patients, reflecting systemic infection affecting the central nervous system. Other signs like fever or tachycardia may also occur, but disorientation is a critical early warning.