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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.
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The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inflamed conjunctiva. The child receives a prescription for an ophthalmic anti-infective ointment. Which instruction should the nurse provide the child's caregivers during discharge education?
- A. Discontinue the ointment once drainage resolves.
- B. Prepare the child for blurry vision after ointment application.
- C. Use a disposable moist wipe to remove eye crusts.
- D. Remove secretions by wiping toward the opposite eye.
Correct Answer: B
Rationale: Ophthalmic ointment can cause temporary blurry vision, and preparing the child for this effect is important.
A newborn with a repaired gastroschisis is transferred to the paediatric unit after several days in the paediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Offer a pacifier for non-nutritive sucking.
- B. Use sterile technique during feedings.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Speak to the healthcare provider about instituting physical therapy.
Correct Answer: A
Rationale: Non-nutritive sucking via a pacifier promotes oral motor skill development, supporting normal feeding behaviors critical for growth.
When developing a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the client to eat a source of sugar if which symptom occurs?
- A. Racing pulse.
- B. Profuse perspiration.
- C. Excessive thirst.
- D. Seeing spots.
Correct Answer: B
Rationale: Profuse perspiration is a symptom of hypoglycemia, requiring immediate sugar intake to raise blood glucose levels.
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.
The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute. Which medication should the nurse withhold until the healthcare provider is notified?
- A. Digoxin.
- B. Furosemide.
- C. Hydralazine.
- D. Enalapril.
Correct Answer: A
Rationale: Digoxin should be withheld if the apical pulse is below 90 beats/minute in infants, as it may indicate toxicity.