Nokea
The mother of a 2-year-old is concerned because the child's right eye seems to turn in toward his nose when he is tired. The nurse should:
- A. Assure the mother that this is a normal event when the child is tired.
- B. Advise the mother to continue to watch his eyes closely and if the problem persists to call the clinic.
- C. Test the child with the cover-uncover test and refer to an ophthalmologist if the test is abnormal.
- D. Explain to the mother that the child will probably outgrow the weakness and she need not be concerned.
Correct Answer: C
Rationale: The cover-uncover test can detect strabismus, which requires referral if confirmed.
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The nurse is caring for a 10-year-old with sickle cell anemia who is experiencing a vaso-occlusive crisis. Which intervention should the nurse prioritize?
- A. Administering antibiotics as prescribed.
- B. Encouraging ambulation to improve circulation.
- C. Providing hydration and pain management.
- D. Applying cold packs to painful joints.
Correct Answer: C
Rationale: Hydration and pain management are critical in vaso-occlusive crises to reduce blood viscosity and alleviate pain, improving outcomes.
A parent asks which nutrient deficiency is common in children with celiac disease. The nurse should respond:
- A. Vitamin C.
- B. Iron.
- C. Vitamin A.
- D. Magnesium.
Correct Answer: B
Rationale: Iron deficiency is common in celiac disease due to malabsorption in the small intestine. Other deficiencies (e.g., vitamin D, B vitamins) may occur, but iron is most frequent.
After 6 months of treatment with diet and exercise, a 12-year-old with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL. The primary care provider has decided to begin metformin (Glucophage). The adolescent asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and:
- A. Replaces natural insulin.
- B. Helps the body make more insulin.
- C. Increases insulin sensitivity.
- D. Decreases carbohydrate adsorption.
Correct Answer: C
Rationale: Metformin reduces hepatic glucose production and increases insulin sensitivity in peripheral tissues, improving glucose uptake. It does not replace insulin, stimulate insulin production, or affect carbohydrate absorption.
A 4-year-old has been scheduled for a cardiac catheterization. To help prepare the family the nurse should:
- A. Advise the family to bring the child to the hospital the night before.
- B. Explain that the child will need a large bandage after the procedure.
- C. Discourage bringing favorite toys that might become associated with pain.
- D. Explain that the child may get up as soon as the vital signs are stable.
Correct Answer: B
Rationale: The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. Preparing the child the night before, bringing favorite toys, and explaining activity restrictions are also important but not the primary focus of this choice.
When teaching an adolescent with a seizure disorder who is receiving valproic acid (Depakene), which sign or symptom should the nurse instruct the client to report to the health care provider?
- A. Three episodes of diarrhea.
- B. Loss of appetite.
- C. Jaundice.
- D. Sore throat.
Correct Answer: C
Rationale: Jaundice indicates potential liver toxicity, a serious side effect of valproic acid, requiring immediate reporting.