Nokea
The nurse is giving care to an infant with a brain tumor. The nurse observes the infant arch the back (see figure). The nurse should:
- A. Notify the physician
- B. Stroke the back to release the arching
- C. Pad the side rails of the crib
- D. Place the child prone
Correct Answer: A
Rationale: The infant has opisthotonos, an indication of brain stem herniation; the nurse should notify the physician immediately and have resuscitation equipment ready. Stroking the back will not relieve the herniation or release the arching. Although the infant may also have a seizure, and padded side rails will prevent injury, the fi rst action is to notify the physician. Placing the child in a prone position will not relieve the herniation or release the arching.
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After the acute stage following an ingestion of drain cleaner by a child, the nurse should be alert for the development of which of the following as a likely complication?
- A. Tracheal stenosis.
- B. Tracheal varices.
- C. Esophageal strictures.
- D. Esophageal diverticula.
Correct Answer: C
Rationale: Corrosive ingestion can scar the esophagus, leading to strictures. Tracheal complications are less common unless the airway is directly affected, and diverticula are not typical.
A male adolescent who underwent repair of an inguinal hernia earlier today and is getting ready to go home receives instructions about resuming physical activities. Which of the following statements would indicate that he has understood the instructions?
- A. I can start riding my bike next week.
- B. I have to skip physical education classes for 2 weeks.
- C. I can start wrestling again in 3 weeks.
- D. I can return to my weight-lifting class in 2 weeks.
Correct Answer: B
Rationale: Avoiding strenuous activities like PE for 2 weeks prevents strain on the surgical site.
A child diagnosed with Wilms' tumor undergoes successful surgery for removal of the diseased kidney. When the child returns to the room, the nurse should place the child in which position?
- A. Modified Trendelenburg.
- B. Sims'.
- C. Semi-Fowler's.
- D. Supine.
Correct Answer: C
Rationale: Semi-Fowler's aids breathing.
During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?
- A. Limiting conversation with the child.
- B. Keeping extraneous noise to a minimum.
- C. Allowing the child to play in the bathtub.
- D. Performing treatments quickly.
Correct Answer: B
Rationale: Minimizing noise reduces sensory stimulation, which can exacerbate irritability in a child with meningitis.
An adolescent with chronic renal failure is scheduled to go home with a peritoneal dialysis catheter in place. When developing the discharge teaching plan for the client and family focusing on psychosocial needs, which of the following areas should be a top priority to include?
- A. Advantages of limiting social activities and contacts for the first few months.
- B. Not disclosing information about the peritoneal dialysis to people outside the family.
- C. Possible effect on body image of the presence of an abdominal catheter.
- D. Importance of relying on parents to do the dialysis and dressing changes.
Correct Answer: C
Rationale: Body image concerns are significant.