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The nurse is assessing an 11-year-old female, using the Tanner Staging of Puberty. Which of the following indicates preadolescent development of the breasts?
- A. Tanner-1.png
- B. Tanner-2.png
- C. Tanner-3.png
- D. Tanner-4.png
Correct Answer: C
Rationale: This figure indicates elevation of the papilla, without breast buds, considered Stage 1 and typical of a preadolescent. Figure 1 shows stage 2, breast bud enlargement; there is elevation of the breast and the diameter of the areola has increased. Figure 2 shows stage 3, enlargement of the breast and areola. Figure 4 shows stage 4, in which there is projection of areola and papilla to form a secondary mound above the level of the breast
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The mother asks the nurse about using a car seat for her toddler who is in a hip spica cast. The nurse should tell the mother:
- A. You can use a seat belt because of the spica cast.'
- B. You will need a specially designed car seat for your toddler.'
- C. You can still use the car seat you already have.'
- D. You'll need to get a special release from the police so that a car seat won't be needed.'
Correct Answer: B
Rationale: A specially designed car seat is required to accommodate the hip spica cast and ensure safety during transport.
The mother of a toilet-trained toddler who was admitted to the hospital for severe gastroenteritis and subsequent dehydration and is now at home asks the nurse why the child still wets the bed. Which of the following should be the nurse's best response?
- A. Hospitalization is a traumatic experience for children, regression is common and it takes time for them to return to their former behavior.
- B. The stress of hospitalization is hard for many children, but usually they have no problems when they return home.
- C. After returning home from being hospitalized, children still feel they should be the center of attention.
- D. Children do not feel comfortable in their home surroundings once they return home from being hospitalized.
Correct Answer: A
Rationale: Regression, like bedwetting, is common after hospitalization due to stress.
A nurse is teaching the family of an 8-year-old boy with acute lymphocytic leukemia about appropriate activities. Which of the following activities should the nurse recommend?
- A. Home schooling.
- B. Restriction from participating in athletic activities.
- C. Avoiding trips to the shopping mall.
- D. Being treated as 'normal' as much as possible.
Correct Answer: D
Rationale: Normal activities promote psychological well-being in leukemia, with precautions for infection and bleeding risks.
An adolescent tells the nurse that the area below his knee has been hurting for several weeks. The nurse should obtain history information about participation in which of the following?
- A. Soccer.
- B. Golf.
- C. Diving.
- D. Swimming.
Correct Answer: A
Rationale: Pain below the knee in adolescents is often associated with Osgood-Schlatter disease, which is common in sports like soccer that involve repetitive knee stress.
The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
- A. A family history of sudden infant death syndrome (SIDS).
- B. A fever of 38.5°C following the 4-month vaccinations.
- C. An acute bilateral ear infection.
- D. Living with a family member who is immunosuppressed.
Correct Answer: C
Rationale: An acute infection is a contraindication for vaccination due to the risk of adverse reactions.