Nokea
The mother of a child with acute laryngotracheobronchitis (LTB) asks why her child must be kept NPO. Which responses would be the most correct?
- A. The epinephrine given causes nausea and vomiting.
- B. The child is being hydrated with IV fluids.
- C. The child is not hungry.
- D. The child's rapid respirations pose a risk for aspiration.
Correct Answer: D
Rationale: Rapid respirations predispose to aspiration. The child is kept hydrated with IV fluids, but this is not the reason that the child must be kept NPO.
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The nurse explains that cognitive impairment is categorized by four levels that depend on the intelligence quotient (IQ). How is a child with an IQ of 45 classified?
- A. Within the normal low range
- B. Educable
- C. Trainable
- D. Severe
Correct Answer: C
Rationale: The category of trainable is identified on the basis of an IQ of 35 to 55.
Which signs/symptoms would be considered classical signs of meningeal irritation?
- A. Positive Kernig sign, diarrhea, and headache
- B. Negative Brudzinski sign, positive Kernig sign, and irritability
- C. Positive Brudzinski sign, positive Kernig sign, and photophobia
- D. Negative Kernig sign, vomiting, and fever
Correct Answer: C
Rationale: Classical manifestations of meningitis include positive Kernig and Brudzinski signs.
When the nurse performs the initial assessment of an adolescent with depression, what is the most important question to ask?
- A. What is making you depressed?
- B. Have you ever thought about suicide?
- C. What could we do to make you happy?
- D. Would you like your friends to visit?
Correct Answer: B
Rationale: Ask direct questions about suicidal thoughts. The discovery of whether the person has an actual plan is an indicator of the seriousness of the situation.
What is the most common clinical manifestation of coarctation of the aorta?
- A. Clubbing of the digits
- B. Upper extremity hypertension
- C. Pedal edema and portal congestion
- D. Loud systolic ejection murmur
Correct Answer: B
Rationale: Coarctation of the aorta results in hypertension in the upper extremities. The pressure in the arms is typically 20 mm Hg higher than in the legs.
Which is a long-term complication of cleft lip and palate?
- A. Cognitive impairment
- B. Altered growth and development
- C. Faulty dentition
- D. Physical abilities
Correct Answer: C
Rationale: The older child with cleft lip and palate may experience psychological difficulties because of the cosmetic appearance of the defect, problems with impaired speech, and faulty dentition.