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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.
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A mother brings her 2-month-old to the well-baby clinic. She mentions that when she kisses her baby, the infant's skin tastes salty. What standard diagnostic test should the nurse prepare the mother for 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 diagnostic for cystic fibrosis, detecting elevated chloride levels.
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 consume a source of sugar if which symptom occurs?
- A. Seeing spots
- B. Profuse perspiration
- C. Racing pulse
- D. Excessive thirst
Correct Answer: B
Rationale: Profuse perspiration indicates hypoglycemia, requiring sugar intake to raise blood glucose.
The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
- A. Demonstrates startle reflex
- B. Plays “peek-a-booâ€
- C. Has doubled birth weight
- D. Turns head to locate sound
Correct Answer: A
Rationale: The startle reflex should disappear by 6 months; its presence suggests neurological issues.
A 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?
- A. Stool containing mucus and blood.
- B. An olive-sized mass in the epigastric region.
- C. Frequent burping accompanied by poor feeding.
- D. Rebound tenderness in the left lower abdominal quadrant.
Correct Answer: B
Rationale: An olive-sized mass suggests pyloric stenosis, a common cause of projectile vomiting.
When caring for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
- A. Monitor peripheral pulses and sensation in the right leg
- B. Cleanse pin sites as prescribed
- C. Check skin for redness and signs of tissue breakdown
- D. Reposition the child every 2 hours
Correct Answer: A
Rationale: Monitoring pulses and sensation is critical to detect vascular or nerve complications from traction.