Nokea
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.
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A nurse is educating parents about essential dietary modifications for their child, who has recently been diagnosed with celiac disease. Which foods should the nurse include in the list of permissible foods for this child?
- A. Rice
- B. Barley
- C. Rye
- D. Oats
Correct Answer: A
Rationale: Rice is gluten-free and safe for celiac disease, unlike barley, rye, or most oats.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?
- A. The thyroxine level is low because the TSH level is high.
- B. High thyroxine levels normally occur in breastfeeding infants.
- C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
- D. The TSH is high because of the low production of T4 by the thyroid.
Correct Answer: D
Rationale: High TSH results from low T4 production, indicating congenital hypothyroidism.
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 nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?
- A. Obtain point-of-care glucose.
- B. Assess urine for ketones.
- C. Check blood pressure.
- D. Review prior insulin prescriptions.
Correct Answer: A
Rationale: Symptoms suggest hyperglycemia; point-of-care glucose testing confirms this and guides treatment.
A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?
- A. Compare the child's vital signs over the past three weeks.
- B. Counsel the parents to pay more attention to the child.
- C. Ask the boy to describe a typical day at school.
- D. Conduct a complete neurological assessment.
Correct Answer: C
Rationale: Asking the boy to describe a typical day at school helps identify potential stressors or psychosocial factors contributing to his non-specific symptoms.