Nokea
The mother asks the nurse whether her child with hemiparesis due to spastic cerebral palsy will be able to walk normally because he can pull himself to a standing position. Which of the following responses by the nurse would be most appropriate?
- A. Ask the doctor what he thinks at your next appointment.'
- B. Maybe, maybe not. How old were you when you first walked?'
- C. It's difficult to predict, but his ability to bear weight is a positive factor.'
- D. If he really wants to walk, and works hard, he probably will eventually.'
Correct Answer: C
Rationale: The ability to bear weight is a positive sign, but predicting normal walking is challenging due to the variability in cerebral palsy outcomes.
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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.
Which of the following beverages should the nurse plan to give a child with leukemia to relieve nausea?
- A. Orange juice.
- B. Weak tea.
- C. Plain water.
- D. A carbonated beverage.
Correct Answer: B
Rationale: Weak tea is gentle and soothing, helping relieve nausea without irritation. Other options may worsen nausea.
The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
- A. A family history of sudden infant death syndrome (SIDS).
- B. A fever of 38.5°C following the 4-month vaccinations.
- C. An acute bilateral ear infection.
- D. Living with a family member who is immunosuppressed.
Correct Answer: C
Rationale: An acute infection is a contraindication for vaccination due to the risk of adverse reactions.
Which of the following should the nurse include in the postoperative care plan for a child after an appendectomy to promote recovery?
- A. Encourage early ambulation.
- B. Administer laxatives daily.
- C. Keep the child NPO for 48 hours.
- D. Apply a heating pad to the abdomen.
Correct Answer: A
Rationale: Early ambulation prevents complications like atelectasis and promotes recovery.
A 3-year-old child receiving chemotherapy after surgery for a Wilms' tumor has developed neutropenia. The parent is trying to encourage the child to eat by bringing extra foods to the room. Which food would not be appropriate for this child?
- A. Fudge.
- B. French fries.
- C. Fresh strawberries.
- D. A milk shake.
Correct Answer: C
Rationale: Raw fruits carry infection risk.