Nokea
The nurse is examining an infant for hip placement and has abducted her flexed legs. The nurse should next:
- A. Rotate the hips.
- B. Extend the legs.
- C. Listen for a 'click.'
- D. Palpate the hips for a mass.
Correct Answer: C
Rationale: Listening for a 'click' (Ortolani's sign) is the next step to detect hip dislocation in developmental dysplasia of the hip after abducting the flexed legs.
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When preparing the teaching plan for the mother of a child with asthma, which of the following should the nurse include as signs to alert the mother that her child is having an asthma attack?
- A. Secretion of thin, copious mucus.
- B. Tight, productive cough.
- C. Wheezing on expiration.
- D. Temperature of 99.4°F (37.4°C).
Correct Answer: C
Rationale: Wheezing on expiration is a hallmark sign of an asthma attack, indicating airway narrowing. The mother should be taught to recognize this to initiate prompt treatment.
The parents of a 12-year-old girl ask why their non-sexually active daughter should receive the human papillomavirus (HPV) vaccine. The nurse should tell the parents:
- A. The vaccine is most effective against cervical cancer if given before becoming sexually active.
- B. Parents are never sure when their child might become sexually active.
- C. HPV is most common in teens and women in their late twenties.
- D. If your daughter is sexually assaulted, she may be exposed to HPV.
Correct Answer: A
Rationale: The HPV vaccine is most effective when given before potential exposure to the virus.
Which of the following medication orders to help relieve discomfort in a child with leukemia should the nurse question?
- A. Acetaminophen (Tylenol).
- B. Acetaminophen with codeine (Tylenol with Codeine).
- C. Ibuprofen (Motrin).
- D. Propoxyphene hydrochloride (Darvon).
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk in leukemia due to its antiplatelet effects, which is dangerous with low platelets. Other medications are safer.
A child is admitted with a diagnosis of possible appendicitis. The child is in acute pain. Which of the following nursing interventions would be appropriate prior to surgery to decrease pain? Select all that apply.
- A. Offer an ice pack.
- B. Apply a heating pad.
- C. Encourage the child to assume a position of comfort.
- D. Limit the child's activity.
- E. Request an order for a cathartic.
Correct Answer: A,C,D
Rationale: Ice, comfortable positioning, and activity limitation reduce pain; heating pads and cathartics may worsen appendicitis.
The nurse talks to an adolescent about how she can tell her friends about her new diagnosis of diabetes. Which of the following behaviors by the adolescent indicates that the adolescent has responded positively to the discussion?
- A. She asks the nurse for material on diabetes for a school paper.
- B. She introduces the nurse to her friends as the nurse to the taught me all about my diabetes.
- C. She says, 'I'll try to tell my friends, but they'll probably quit hanging out with me.'
- D. She asks her friends what they think about someone who has a lifelong illness.
Correct Answer: A
Rationale: Requesting materials indicates proactive engagement and willingness to share knowledge, reflecting a positive response. Other options show hesitation or indirect approaches.