Nokea
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse's best response?
- A. Newborns cry and cannot be distracted to stop crying.
- B. When faced with a pain, newborns try to roll away from it.
- C. Newborns typically move their whole body in response to pain.
- D. Pain causes the newborn to withdraw the affected part.
Correct Answer: C
Rationale: Newborns exhibit a generalized body response to pain, such as squirming or thrashing.
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A 5-year-old child brought to the clinic with several superficial sores on the front of the left leg is diagnosed with impetigo. Which of the following instructions should the nurse give the parent?
- A. Wash the child's legs gently three times per day with a mild soap.
- B. Cover the sores with loose gauze.
- C. Add the child to go back to school after 24 hours of treatment.
- D. Have the child return to the clinic the next week for a follow-up examination.
Correct Answer: C
Rationale: Impetigo is contagious until treated for 24 hours with antibiotics, after which the child can return to school. Gentle washing is helpful but not the primary instruction, gauze may trap moisture, and follow-up timing depends on response.
Which of the following is a normal response from an adolescent who has just returned to her room after an appendectomy?
- A. I'll need plastic surgery for this scar.
- B. I'm worried about the size of my scar.
- C. I don't want to have any pain.
- D. What will my boyfriend say about the scar?
Correct Answer: B
Rationale: Concern about scar size is a typical adolescent response, reflecting body image concerns.
After surgery to repair a tracheoesophageal fistula, an infant receives gastrostomy tube feedings. After feeding the infant by this method, the nurse positions the infant with the head elevated for approximately 30 minutes, primarily to help accomplish which of the following?
- A. Promote intestinal peristalsis.
- B. Prevent regurgitation of formula.
- C. Relieve pressure on the surgical site.
- D. Associate eating with a pleasurable experience.
Correct Answer: B
Rationale: Head elevation reduces the risk of formula reflux, protecting the surgical site and airway.
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which of the following nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply.
- A. Offer an ice pack.
- B. Apply a heating pad.
- C. Encourage the child to assume a position of comfort.
- D. Limit the child's activity.
- E. Request an order for a cathartic.
Correct Answer: A,C,D
Rationale: Ice, comfortable positioning, and activity limitation reduce pain; heating pads and cathartics may worsen appendicitis.
Which of the following meals would be most appropriate for a 15-year-old with glomerulonephritis with severe hypertension?
- A. Egg noodles, hamburger, canned peas, milk.
- B. Baked ham, baked potato, pear, canned carrots, milk.
- C. Baked chicken, rice, beans, orange juice.
- D. Hot dog on a bun, corn chips, pickle, cookie, milk.
Correct Answer: C
Rationale: Low-sodium diet is recommended.