Nokea
The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?
- A. Administer topical antibiotic therapy daily.
- B. Provide passive range of motion exercises.
- C. Ensure no weight bearing on the affected extremity.
- D. Schedule ice pack applications to the infected area.
Correct Answer: C
Rationale: No weight bearing on the affected extremity prevents further damage during the initial treatment phase of osteomyelitis.
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A male adolescent arrives at the clinic and reports intense pain in the testicular area that occurred during football practice at high school. The nurse observes the scrotum and identifies significant erythema and swelling. Which action should the nurse take?
- A. Report the findings immediately to the healthcare provider.
- B. Obtain a swab of secretions from the penis and urethra.
- C. Collect a sterile urine sample for culture and sensitivity.
- D. Provide the adolescent with a urinal for urinary hesitancy.
Correct Answer: A
Rationale: Significant erythema and swelling suggest testicular torsion, a medical emergency requiring immediate reporting.
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.
The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement.
- B. The child is afebrile with normal vital signs postoperatively.
- C. An intracranial pressure (ICP) monitoring probe is in place.
- D. The child reports no evidence of continuous headaches.
Correct Answer: D
Rationale: The absence of continuous headaches indicates the VP shunt is functioning normally by relieving pressure on the brain, a primary symptom of hydrocephalus.
The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?
- A. Rebound tenderness in the left lower abdominal quadrant.
- B. Stool that consists of mucus and blood.
- C. Olive-size mass in the epigastric area.
- D. Frequent burping accompanied by poor feeding.
Correct Answer: C
Rationale: An olive-size mass in the epigastric area is characteristic of pyloric stenosis, associated with projectile vomiting.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?
- A. The TSH is high because of the low production of T4 by the thyroid.
- B. The thyroxine level is low because the TSH level is high.
- C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
- D. High thyroxine levels normally occur in breastfeeding infants.
Correct Answer: A
Rationale: High TSH levels are a compensatory response to low T4 production, indicating congenital hypothyroidism, which requires prompt treatment to prevent developmental delays.