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The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
- A. Exercise in a swimming pool.
- B. Begin a training program lifting weights and running.
- C. Perform passive range of motion exercises twice daily.
- D. Splint affected joints during activity.
Correct Answer: A
Rationale: Exercising in a swimming pool is low-impact, reduces joint stress, and improves strength and mobility, making it ideal for JIA.
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The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?
- A. Hypotension and tachycardia
- B. Vigorous feeding and satiation
- C. Fever
- D. Hemiplegia
Correct Answer: A
Rationale: Aortic stenosis can reduce cardiac output, leading to hypotension, with tachycardia as a compensatory response.
Which snack choice by a school-aged child with gastroesophageal reflux indicates to the nurse that the child understands the dietary restrictions?
- A. Chocolate milkshake
- B. Sugar cookies
- C. Tacos
- D. Pizza
Correct Answer: B
Rationale: Sugar cookies are less likely to trigger GERD symptoms compared to high-fat or acidic foods.
The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Place a toy in the child's hands while listening to the breath sounds.
- B. Allow the child to use a stethoscope on a stuffed animal.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Have the child blow a cotton ball and have the parent catch it.
Correct Answer: B
Rationale: Using a stethoscope on a stuffed animal engages the child, reducing fear and improving cooperation.
The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Which finding should the nurse report to the healthcare provider immediately?
- A. Jaundice
- B. Swelling in the hands or feet
- C. Ulcers on the legs
- D. Chest pain
Correct Answer: D
Rationale: Chest pain may indicate acute chest syndrome, a life-threatening complication requiring immediate reporting.
During a routine clinic visit, a nurse finds that a 5-year-old girl's systolic blood pressure is above the 90th percentile. What should be the nurse's subsequent action?
- A. Refer the child to the healthcare provider and schedule a blood pressure evaluation in two weeks.
- B. Perform a comprehensive assessment and avoid repeated blood pressure measurements during the examination.
- C. Take the child's blood pressure three times during the visit and record the highest reading.
- D. Measure the blood pressure twice more during the visit and calculate the average of the three readings.
Correct Answer: D
Rationale: Averaging three readings ensures accuracy of elevated blood pressure findings.