Nokea
The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler?
- A. 1/2 cup orange juice
- B. Dry, sweetened cereal
- C. Raw carrot sticks
- D. Slice of cheese
Correct Answer: D
Rationale: A slice of cheese (D) is a nutrient-dense, easy-to-chew snack suitable for a toddler, providing protein and calcium. Orange juice (A) is high in sugar, sweetened cereal (B) lacks nutritional value, and raw carrot sticks (C) pose a choking hazard.
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The nurse is talking with the parent of an adolescent client who has infectious mononucleosis. Which of the following statements by the parent would require follow-up?
- A. My child may take acetaminophen for fever or discomfort.
- B. My child will need to complete a full course of antibiotic therapy.
- C. My child should avoid participating in contact sports for at least 3 weeks.
- D. My child may continue to experience fatigue after the fever and sore throat subside.
Correct Answer: B
Rationale: Mononucleosis is viral, so antibiotics (B) are not indicated, requiring follow-up. Acetaminophen (A), avoiding sports (C), and prolonged fatigue (D) are correct.
Which of the following situations is most likely to produce sepsis in the neonate?
- A. Maternal diabetes
- B. Prolonged rupture of membranes
- C. Cesarean delivery
- D. Precipitous vaginal birth
Correct Answer: B
Rationale: Prolonged rupture of membranes. Premature rupture of the membranes (PROM) is a leading cause of newborn sepsis. After 12-24 hours of leaking fluid, measures are taken to reduce the risk to mother and the fetus/newborn.
The nurse is with a client with obsessive-compulsive disorder who counts backwards several times each day. Which of the following statements by the client would indicate an improvement in the client's condition? Select all that apply.
- A. I take a short, brisk walk to decompress when I begin to feel anxious.
- B. My neighbor goes grocery shopping for me because I get anxious and begin counting.
- C. Having a stressful job worsens my anxiety, but I use deep-breathing exercises to manage it.
- D. Counting helps me cope with my anxiety. It does not hurt anyone, and it is better than drinking alcohol.
- E. I used to start counting as soon as I boarded the bus, but now I can ride the bus for 30 minutes without counting.
Correct Answer: A,C,E
Rationale: Statements A, C, and E indicate improvement as the client uses adaptive coping strategies (walking, deep breathing) and reports reduced compulsive behavior (delayed counting). Statement B shows reliance on others, and D justifies the compulsion, both indicating no improvement.
The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find?
- A. Complaints of numbness and tingling in feet
- B. Wheezing noted when lung sounds auscultated
- C. Excessive perspiration
- D. Difficulty sleeping
Correct Answer: A
Rationale: Complaints of numbness and tingling in feet. A child who has unusual neurologic signs or symptoms, neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings.
The nurse is caring for a client with a terminal illness who is expected to die during the shift. The nurse notes that the client has loud, wet respirations. Which of the following medications would effectively treat this finding?
- A. IM lorazepam
- B. sublingual atropine
- C. transdermal fentanyl
- D. sublingual ondansetron
Correct Answer: B
Rationale: Sublingual atropine (B) reduces salivary secretions, alleviating 'death rattle.' Lorazepam (A) is for anxiety, fentanyl (C) for pain, and ondansetron (D) for nausea.