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The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. What intervention should the nurse implement?
- A. Obtain the essential information as quickly as possible.
- B. Include the child's toy in the collection of information.
- C. Document interactions between the parent and the child.
- D. Ignore the child's behavior, directing Questions to a parent.
Correct Answer: B
Rationale: Using the toy reduces fear, creating a comfortable environment for history collection.
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A 7-year-old child has been admitted to the hospital with a diagnosis of acute rheumatic fever. When taking a health history from the child's mother, which recent illness is of most significance?
- A. Chickenpox.
- B. Mumps.
- C. Sore throat.
- D. Influenza.
Correct Answer: C
Rationale: A recent untreated strep throat can lead to acute rheumatic fever.
The parents of a 14-month-old child, hospitalized due to febrile seizures, express their concern to the nurse about their child having seizures for life. What information should the nurse share with these parents?
- A. Avoid overstimulation as it can trigger seizure activity.
- B. Assure the parents that the frequency of febrile seizures decreases as the child ages.
- C. Suggest giving the child a sponge bath when the temperature exceeds 100.6°F (38.1°C).
- D. Advise the prophylactic use of Ibuprofen to prevent febrile seizures.
Correct Answer: B
Rationale: Febrile seizures typically decrease with age, often resolving by age 5.
When developing a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the client to consume a source of sugar if which symptom occurs?
- A. Seeing spots
- B. Profuse perspiration
- C. Racing pulse
- D. Excessive thirst
Correct Answer: B
Rationale: Profuse perspiration indicates hypoglycemia, requiring sugar intake to raise blood glucose.
The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure. The infant's vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute. Which medication should the nurse hold and inform the health care provider?
- A. Enalapril
- B. Digoxin
- C. Furosemide
- D. Hydralazine
Correct Answer: B
Rationale: The infant's apical pulse of 88 beats/minute is below the normal range (100-160 beats/minute) for an eight-month-old, indicating a need to hold Digoxin and notify the provider.
The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
- A. Demonstrates startle reflex
- B. Plays “peek-a-booâ€
- C. Has doubled birth weight
- D. Turns head to locate sound
Correct Answer: A
Rationale: The startle reflex should disappear by 6 months; its presence suggests neurological issues.