Nokea
The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take?
- A. Document the finding
- B. Palpate scrotum for testicular descent
- C. Assess for bladder distension
- D. Auscultate bowel sounds
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to document the finding. The infant voiding a urinary stream from the ventral surface of the penis suggests hypospadias, a condition where the urethral opening is on the underside of the penis. This finding is crucial information that needs to be documented for further evaluation. Palpating the scrotum for testicular descent, assessing for bladder distension, and auscultating bowel sounds are not appropriate actions based on the presented scenario and do not address the specific concern of the urinary stream location.
You may also like to solve these questions
A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?
- A. Remove the child with HIV from the foster home.
- B. Report the exposure of the child with HIV to the health department.
- C. Place the child with HIV in reverse isolation.
- D. Review the immunization documentation of the child with HIV.
Correct Answer: D
Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV. This step ensures that the child has received the necessary vaccines to protect against pertussis and other preventable diseases. It is essential to verify the immunization status to provide appropriate care and prevent further transmission of infectious diseases within the foster home. Removing the child from the foster home (Choice A) may not be necessary if the child is adequately protected through immunization. Reporting the exposure to the health department (Choice B) is important but not the first action. Placing the child in reverse isolation (Choice C) is not indicated for pertussis exposure.
When caring for a child experiencing severe asthma symptoms, which medication should the practical nurse anticipate being administered first?
- A. Inhaled corticosteroids.
- B. Oral corticosteroids.
- C. Short-acting beta agonists.
- D. Leukotriene receptor antagonists.
Correct Answer: C
Rationale: In the management of acute asthma exacerbations, the first-line medication for quick relief of bronchoconstriction is a short-acting beta agonist, such as albuterol. These medications help to rapidly open up the airways, providing immediate relief to the patient. Inhaled corticosteroids are more commonly used for long-term control of asthma symptoms, while oral corticosteroids and leukotriene receptor antagonists are often reserved for more severe or chronic cases. Therefore, in a child experiencing severe asthma symptoms, the practical nurse should anticipate the administration of short-acting beta agonists as the initial intervention to provide quick relief and improve breathing.
A 9-year-old child is brought to the clinic with a fever, rash, and swollen joints. The nurse notes that the child had a sore throat two weeks ago that was not treated. What condition should the nurse suspect?
- A. Scarlet fever
- B. Rheumatic fever
- C. Kawasaki disease
- D. Juvenile rheumatoid arthritis
Correct Answer: B
Rationale: In this scenario, the child's symptoms of fever, rash, and swollen joints following an untreated sore throat two weeks ago are indicative of rheumatic fever. Rheumatic fever can develop as a complication of untreated streptococcal infections, leading to systemic inflammation and affecting various organs, including the joints. This condition manifests with symptoms such as fever, rash, and swollen joints, aligning with the child's presentation in this case. Scarlet fever typically presents with a sandpapery rash and strawberry tongue but does not involve joint inflammation. Kawasaki disease presents with fever, rash, and mucous membrane changes but does not typically involve joint swelling. Juvenile rheumatoid arthritis can cause joint swelling but is not directly linked to a recent untreated sore throat.
What response should the practical nurse (PN) provide when a school-age child asks to talk with a dying sister?
- A. Talk loudly to ensure the dying person hears and recognizes others' voices.
- B. Touch can provide a tactile presence if the dying person does not respond to words.
- C. Sitting close offers the dying person the sensation of others' presence.
- D. Although the dying person may not respond, they can still hear what is said.
Correct Answer: D
Rationale: The correct response is D because it is believed that hearing is the last sense to go. Even if the dying person does not respond, speaking to them can still provide comfort. Choice A is incorrect because talking loudly is not necessary and can be distressing. Choice B is incorrect as it focuses on touch rather than the sense of hearing. Choice C is incorrect because sitting close may not necessarily help the dying person hear better.
What is the best response for a two-year-old boy who begins to cry when the mother starts to leave?
- A. Let's wave bye-bye to mommy.
- B. Two-year-olds usually stop crying the minute the parent leaves.
- C. Now be a big boy. Mommy will be back soon.
- D. Let's wave bye-bye to mommy.
Correct Answer: D
Rationale: The best response for a two-year-old boy who begins to cry when the mother starts to leave is to wave bye-bye to mommy. This action helps the child understand that the separation is temporary and gives him a sense of closure. Choice A is the correct answer. Choice B is incorrect as it generalizes the behavior of two-year-olds. Choice C may invalidate the child's feelings by telling him to 'be a big boy' instead of acknowledging his emotions and providing comfort.