Nokea
The caregiver is caring for a 3-year-old child with a diagnosis of gastroenteritis. The child has had several episodes of vomiting and diarrhea over the past 24 hours. What is the caregiver's priority assessment?
- A. Monitor the child's weight
- B. Assess the child's hydration status
- C. Evaluate the child's nutritional intake
- D. Check the child's temperature
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
- A. Turn the infant on the left side braced against the crib when sleeping.
- B. Prop the infant in a sitting position with a cushion when not sleeping.
- C. Place a small pillow under the infant's head while lying on the back.
- D. Position the infant on the stomach occasionally when awake and active.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In a 12-year-old child with a history of epilepsy brought to the emergency department after experiencing a 10-minute seizure, what is the nurse's priority intervention?
- A. Administer oxygen
- B. Administer antiepileptic medication as prescribed
- C. Monitor the child's vital signs
- D. Check the child's blood glucose level
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 14-year-old adolescent with a history of substance abuse is brought to the emergency department by the parents, who suspect that the adolescent has relapsed. What is the nurse's priority action?
- A. Obtain a urine sample for toxicology screening
- B. Discuss treatment options with the parents
- C. Establish a therapeutic relationship with the adolescent
- D. Administer a medication to reverse the effects of the substance
Correct Answer: A
Rationale: In this scenario, the nurse's priority action should be to obtain a urine sample for toxicology screening. This step is crucial in identifying the substances involved in the relapse, which will guide appropriate treatment strategies. Establishing a therapeutic relationship and discussing treatment options come after obtaining necessary diagnostic information to ensure a comprehensive care plan.
The practical nurse is reinforcing education with the parents of a child prescribed iron supplements for iron-deficiency anemia. Which statement by the parents indicates they need further instruction?
- A. We will give the iron supplement with milk to reduce stomach upset.
- B. We should give the iron supplement with orange juice to improve absorption.
- C. The supplement may cause the stools to appear dark or black.
- D. We should store the iron supplements out of reach of children.
Correct Answer: A
Rationale: Iron supplements should not be given with milk as calcium can interfere with iron absorption. Instead, it is recommended to give it with a source of vitamin C, such as orange juice, to enhance iron absorption. Giving iron supplements with milk may decrease the absorption of iron and should be avoided in this case.
An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test that was drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?
- A. Ask when the adolescent was last seen at the clinic
- B. Tell the mother to have the teenager call the clinic
- C. Provide the mother with the findings
- D. Explain that the information cannot be released without the 18-year-old's permission
Correct Answer: D
Rationale: When an individual turns 18, they are legally considered an adult, and privacy laws mandate that their consent is required before sharing their medical information with others. It is important to respect the adolescent's autonomy and privacy rights by explaining to the mother that the information cannot be disclosed without the 18-year-old's permission.