Nokea
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?
- A. Hypotension and tachycardia
- B. Vigorous feeding and satiation
- C. Fever
- D. Hemiplegia
Correct Answer: A
Rationale: Aortic stenosis can reduce cardiac output, leading to hypotension, with tachycardia as a compensatory response.
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A nurse is providing care for a toddler diagnosed with autism spectrum disorder and failure to thrive. What strategy should the nurse employ?
- A. Propose food even if the child shows no interest.
- B. Integrate play activities during meal times.
- C. Establish regular meal times.
- D. Permit a variety of food options.
Correct Answer: C
Rationale: Regular meal times provide structure, aiding nutrition in autism spectrum disorder.
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. Fecal-fat test.
- B. Sweat-chloride test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: B
Rationale: The sweat-chloride test is the standard screening for cystic fibrosis due to elevated salt levels in sweat.
When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?
- A. Apply soft restraints to all four extremities.
- B. Assess the dorsal surface of the feet for an IV site.
- C. Instruct parents to sing or croon to the infant.
- D. Select a site that is least restrictive to the infant.
Correct Answer: D
Rationale: Choosing a least restrictive site minimizes distress and allows easier movement post-IV insertion.
The nurse is evaluating a preschool-aged child who is presenting with symptoms of flank pain, dysuria, and a low-grade fever. What additional information should the nurse obtain from the parent to determine if the child might have a urinary tract infection?
- A. Frequency of urination
- B. Any recent changes in diet
- C. Presence of any unusual odors in the urine
- D. Any changes in the color of the urine
Correct Answer: A
Rationale: Increased urination frequency is a common UTI symptom in children, aiding diagnosis.
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
- A. Apply lotion to hands and feet.
- B. Encourage the parents to rest when possible.
- C. Make a list of foods that the child likes.
- D. Place the child in a quiet environment.
Correct Answer: D
Rationale: Placing the child in a quiet environment reduces stimulation and promotes rest, addressing irritability, a primary symptom of Kawasaki disease.