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The nurse is assessing a child with acute glomerulonephritis who presents with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?
- A. Positive rapid strep test of oropharynx.
- B. Blood pressure 88/50 mmHg.
- C. Maculopapular rash over trunk of body.
- D. Weight loss.
Correct Answer: A
Rationale: A positive strep test confirms a recent streptococcal infection, a common cause of acute glomerulonephritis, requiring reporting.
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The nurse is caring for a toddler with autism spectrum disorder and failure to thrive. Which intervention should the nurse implement?
- A. Provide structured meal times.
- B. Offer food even if disinterested.
- C. Incorporate play during meals.
- D. Allow multiple food choices.
Correct Answer: A
Rationale: Structured meal times promote routine and reduce sensory overload, aiding feeding in children with autism spectrum disorder.
An adolescent client reports to the nurse of walking with a limp due to pain localized in the right knee which worsens at night but denies any recent injury or trauma. The nurse observes swelling and tenderness in the right lower thigh, and imaging results reveal radial ossification in the soft tissues. Which condition should the nurse consider as the probable cause of the findings?
- A. Osteosarcoma
- B. Growing pains
- C. Rhabdomyolysis
- D. Hemosiderosis
Correct Answer: A
Rationale: Pain, swelling, tenderness, and radial ossification suggest osteosarcoma, a common bone tumor in adolescents, unlike the other conditions.
The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving this client?
- A. Cross the arms and legs.
- B. Perform a log roll.
- C. Raise the hips.
- D. Flex the knees.
Correct Answer: B
Rationale: The log roll technique maintains spinal alignment, critical after surgical spinal instrumentation.
When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?
- A. Select a site that is least restrictive to the infant.
- B. Assess dorsal surface of feet for an IV site.
- C. Instruct parents to sing or croon to the infant.
- D. Apply soft restraints to all four extremities.
Correct Answer: A
Rationale: Selecting a least restrictive site minimizes discomfort and maintains mobility, ensuring safe and effective IV placement.
A child who weighs 30 kg is experiencing a grand mal seizure. The healthcare provider prescribes diazepam 0.3 mg/kg/dose intravenous (IV) STAT. The medication is available in 5 mg/mL vials. How many mL should the nurse administer?
- A. 1.8 mL
Correct Answer: A
Rationale: The dose is calculated as 30 kg x 0.3 mg/kg = 9 mg. Dividing by 5 mg/mL gives 1.8 mL, which is the correct volume to administer.