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The nurse is assessing a preschool-aged child who presents with flank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?
- A. Pale urine.
- B. Increased fluid intake.
- C. New onset bedwetting.
- D. Voiding every 4 hours.
Correct Answer: C
Rationale: New onset bedwetting in a preschool-aged child can indicate a urinary tract infection, as it may reflect irritation or loss of bladder control.
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During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?
- A. Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks.
- B. Measure the child's blood pressure three times during the visit and determine the highest of the readings.
- C. Conduct a head-to-toe assessment and omit repeated blood pressures during the examination.
- D. Take the blood pressure two more times during the visit and determine the average of the three readings.
Correct Answer: D
Rationale: Taking the blood pressure two more times and averaging the readings provides a more accurate assessment.
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Have the child blow a cotton ball and have the parent catch it.
- B. Place a toy in the child's hands while listening to the breath sounds.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Allow the child to use a stethoscope on a stuffed animal.
Correct Answer: D
Rationale: Allowing the child to use a stethoscope on a stuffed animal familiarizes them with the procedure, increasing cooperation.
A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?
- A. Sweat-chloride test.
- B. Faecal-fat test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: A
Rationale: Salty-tasting skin is a hallmark of cystic fibrosis, and the sweat-chloride test is the standard diagnostic test.
A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
- A. List of achievement timeline for developmental milestones.
- B. Reactions to any previous hospitalizations.
- C. A history of rubella, rubeola, or chicken pox.
- D. Mother's use of alcohol, drugs, or cigarettes during pregnancy.
Correct Answer: B
Rationale: Previous hospitalization reactions help anticipate and address fears, aiding in care planning.
The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored. This child should receive follow-up assessment for what condition?
- A. Intussusception.
- B. Biliary atresia.
- C. Hirschsprung's disease.
- D. Huntington's disease.
Correct Answer: B
Rationale: Jaundice and tea-colored urine suggest biliary atresia, requiring urgent follow-up to prevent liver damage.