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On a home visit following discharge from the hospital after treatment for severe gastroenteritis, the mother tells the nurse that her toddler answers "No!" and is difficult to manage. After discussing this further with the mother, the nurse explains that the child's behavior is most likely the result of which of the following?
- A. Beginning leadership skills.
- B. Inherited personality trait.
- C. Expression of individuality.
- D. Usual lack of interest in everything.
Correct Answer: C
Rationale: Toddlers often assert independence through oppositional behavior.
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Which of the following statements obtained from the nursing history of a toddler should alert the nurse to suspect that the child has had a febrile seizure?
- A. The child has had a low-grade fever for several weeks.
- B. The family history is negative for convulsions.
- C. The seizure occurred with a necessary arrest.
- D. The seizure occurred when the child had a respiratory infection.
Correct Answer: D
Rationale: Febrile seizures are associated with acute fever, often during infections like respiratory infections, in young children.
A nurse administers ranitidine (Zantac) instead of cetirizine (Zyrtec) to an 8-year-old with asthma. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action. The charge nurse should tell the nurse:
- A. If you do not report the error, I will have to.
- B. Reporting the error helps to identify system problems to improve client safety.
- C. Notify the client's physician to see if she wants this reported.
- D. This is not a serious mistake so reporting it will not affect your position.
Correct Answer: B
Rationale: Reporting the error helps identify system problems to improve client safety, promoting a culture of transparency and quality improvement.
An 11-year-old is admitted for treatment of an asthma attack. Which of the following indicates immediate intervention is needed?
- A. Thin, copious mucous secretions.
- B. Productive cough.
- C. Intercostal retractions.
- D. Respiratory rate of 20 breaths/minute.
Correct Answer: C
Rationale: Intercostal retractions indicate significant respiratory distress in an asthma attack, as they reflect increased effort to breathe due to airway obstruction. This requires immediate intervention to prevent further deterioration.
A school-age child who has received burns over 60% of his body is to receive 2,000 mL of I.V. fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump?
Correct Answer: 250
Rationale: Dividing 2,000 mL by 8 hours yields 250 mL/hour. This ensures fluid resuscitation meets burn protocol (e.g., Parkland formula) to maintain hemodynamic stability.
A nurse is teaching parents of a child with PKU about dietary management. Which instruction is most important?
- A. Avoid all fruits and vegetables.
- B. Monitor phenylalanine levels regularly.
- C. Use high-protein supplements.
- D. Limit water intake.
Correct Answer: B
Rationale: Regular monitoring of phenylalanine levels ensures dietary compliance and prevents toxicity. Fruits and vegetables are allowed, high-protein foods are avoided, and water restriction is unnecessary.