Nokea
The nurse formulates the nursing diagnosis Imbalanced Nutrition: Less than body requirements related to negative feeding patterns for a 5-month-old infant diagnosed with failure to thrive. To meet the short-term outcomes of the infant's plan of care, the nurse should expect to do which of the following?
- A. Instruct the parents in proper feeding techniques.
- B. Give infant formula that has 24 calories/ounce.
- C. Provide consistent staff to care for the infant.
- D. Allow the infant to sit in a high chair during feedings.
Correct Answer: A
Rationale: Teaching proper feeding techniques corrects negative patterns, improving intake. Higher-calorie formula or consistent staff are secondary, and high chairs are unsuitable for a 5-month-old.
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A 17-year-old female with severe nodular acne is considering treatment with isotretinoin (Accutane). Prior to beginning the medication, the nurse explains that the client will be required to:
- A. Enroll in a risk management plan.
- B. Egypt in a risk management plan.
- C. Begin an effective form of birth control.
- D. Temporarily give up sports.
Correct Answer: C
Rationale: Isotretinoin has a high risk of teratogenicity, requiring strict contraception to prevent pregnancy during treatment. A risk management plan (e.g., iPLEDGE) is also required, but the most critical initial step emphasized is effective birth control.
What is the most appropriate method to use when drawing blood from a child with hemophilia?
- A. Use finger punctures for lab draws.
- B. Be prepared to administer platelets for prolonged bleeding.
- C. Apply heat to the extremity before venipunctures.
- D. Schedule all labs to be drawn at one time.
Correct Answer: D
Rationale: Scheduling labs together minimizes venipunctures, reducing bleeding risk in hemophilia. Finger punctures and heat increase bleeding, and platelets are not standard.
When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: Bending forward at the waist with arms hanging freely allows the nurse to observe for spinal asymmetry, a key sign of scoliosis.
The nurse is caring for a 5-year-old boy who is taking prednisolone for nephrotic syndrome. The child is at the 75th percentile for height and has a blood pressure of 114/73. The nurse compares the reading to the below blood pressure levels for boys age and height percentiles. The nurse determines that the blood pressure represents a change and notifies the primary care provider of the assessment of:
- A. Hypotension.
- B. Prehypertension.
- C. Hypertension.
- D. Hypertension stage II.
Correct Answer: C
Rationale: BP indicates hypertension.
Anticipating that a 3-year-old child in traction will have need for diversion, what should the nurse offer the child?
- A. I know game.
- B. Blocks.
- C. Hand puppets.
- D. Marbles.
Correct Answer: C
Rationale: Hand puppets are an engaging, age-appropriate diversion for a 3-year-old, promoting interaction without requiring mobility.