Nokea
The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first:
- A. Administer oxygen.
- B. Institute rewarming.
- C. Prepare for intubation.
- D. Start an intravenous infusion.
Correct Answer: A
Rationale: Administering oxygen addresses hypoxia, the primary concern in near-drowning, to stabilize the child's condition.
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Which of the following should the nurse include in the plan of care for an infant with severe diarrhea to prevent skin breakdown?
- A. Changing diapers every 4 hours.
- B. Applying a petroleum-based ointment.
- C. Using harsh soaps for cleaning.
- D. Keeping the skin exposed to air.
Correct Answer: B
Rationale: Petroleum-based ointment protects the skin from irritation due to frequent stools.
A 1-year-old child is scheduled for surgery to correct hypospadias and chordee. The nurse explains to the parents that this is the preferred time for surgical repair based on which of the following?
- A. At this age, the child will experience less pain.
- B. The child is too young to have developed castration anxiety.
- C. The child will not remember the surgical experience.
- D. The repair is easier to perform after the child is toilet trained.
Correct Answer: C
Rationale: Younger children may not remember the experience.
A child undergoes rehydration therapy after having severe gastroenteritis. After teaching the parents about dietary management, the nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet?
- A. Regular.
- B. Clear liquid.
- C. Full liquid.
- D. Soft.
Correct Answer: D
Rationale: A soft diet is appropriate post-rehydration to ease digestion.
A nurse is making an initial visit to a family with a 3-year-old child with early Duchenne's muscular dystrophy. Which of the following findings is expected with the missing child?
- A. Contractures of the large joints.
- B. Enlarged calf muscles.
- C. Difficulty riding a tricycle.
- D. Small, weak muscles.
Correct Answer: B
Rationale: Enlarged calf muscles due to pseudohypertrophy are a hallmark of early Duchenne's muscular dystrophy, caused by fatty infiltration of muscle tissue.
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." The nurse should:
- A. Explain that completing a teaching checklist is required by the hospital.
- B. Help the client find information on the Internet.
- C. Provide the client with written information instead.
- D. Explain that information found on the Internet cannot be trusted.
Correct Answer: B
Rationale: Assisting with finding reliable online information respects the adolescent's autonomy.