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Preoperatively, the nurse develops a plan to prepare a 7-month-old infant psychologically for a scheduled herniorrhaphy the next day. Which of the following should the nurse expect to implement to accomplish this goal?
- A. Explaining the preoperative and postoperative procedures to the mother.
- B. Having the mother stay with the infant.
- C. Making sure the infant's favorite toy is available.
- D. Allowing the infant to play with surgical equipment.
Correct Answer: B
Rationale: The mother's presence provides comfort and reduces anxiety for a 7-month-old.
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Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
- A. A drop in blood pressure.
- B. An increase in temperature.
- C. Auscultation of moist crackles.
- D. Marked increase in urine output.
Correct Answer: C
Rationale: Moist crackles indicate fluid in the lungs, a sign of circulatory overload.
Because of the risks associated with administration of factor VIII concentrate, the nurse should teach the child's family to recognize and report which of the following?
- A. Yellowing of the skin.
- B. Constipation.
- C. Abdominal distention.
- D. Puffiness around the eyes.
Correct Answer: A
Rationale: Yellowing of the skin (jaundice) may indicate hepatitis, a risk with factor VIII. Other symptoms are less directly related to factor risks.
A nurse is assessing an 8-year-old with diabetes who is experiencing hyperglycemia. Which symptom[s] indicate(s) that the hyperglycemia requires immediate intervention? Select all that apply.
- A. Weakness.
- B. Thirst.
- C. Shakiness.
- D. Hunger.
- E. Headache.
- F. Irritability.
- G. Dizziness.
Correct Answer: B,E,F
Rationale: Thirst, headache, and irritability are hallmark symptoms of hyperglycemia progressing to diabetic ketoacidosis, requiring immediate intervention. Weakness, shakiness, hunger, and dizziness suggest hypoglycemia instead.
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the mother to relate which of the following about the infant's crying and episodes of pain?
- A. Constant accompanied by leg extension.
- B. Intermittent with knees drawn to the chest.
- C. Shrill during ingestion of solids.
- D. Intermittent while being held in the mother's arms.
Correct Answer: B
Rationale: Intussusception causes intermittent pain with knees drawn to the chest due to bowel obstruction.
To determine if a blood pressure reading is normal, the nurse must know which information about the child? Select all that apply.
- A. Age.
- B. Body mass index (BMI).
- C. A secret.
- D. Height.
- E. Occipital frontal circumference (OFC).
- F. Weight.
Correct Answer: A,D,F
Rationale: Age, height, and weight are key factors in determining normal blood pressure ranges.