Nokea
The nurse is taking vital signs on a group of assigned preschool-aged children. Which assessment finding would indicate the need for further action?
- A. Respiratory rate of 20 breaths per minute
- B. Heart rate of 89 beats per minute
- C. Heart rate of 120 beats per minute
- D. Respiratory rate of 24 breaths per minute
Correct Answer: C
Rationale: A heart rate of 120 beats per minute is high for a preschool-aged child and may indicate an underlying issue that requires further assessment. A respiratory rate of 20 breaths per minute (choice A) is within the normal range for preschool children. Similarly, a heart rate of 89 beats per minute (choice B) falls within the expected range. A respiratory rate of 24 breaths per minute (choice D) is slightly elevated but may not be as concerning as a heart rate of 120 beats per minute.
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Which distraction technique should be used for an adolescent child during a painful procedure?
- A. Blowing bubbles
- B. Guided imagery
- C. EMLA cream
- D. Sucrose solution
Correct Answer: B
Rationale: The correct answer is B: Guided imagery. Guided imagery is an effective distraction technique for adolescents as it helps them focus on positive mental images instead of the pain. This technique can be a powerful tool in managing pain and anxiety during procedures. Blowing bubbles (choice A) may be more suitable for younger children as it can engage them visually and help distract them. EMLA cream (choice C) is a topical anesthetic and not a distraction technique. Sucrose solution (choice D) is used for pain relief in infants, not typically for adolescents undergoing painful procedures.
How is family systems theory best described?
- A. The family is viewed as the sum of individual members
- B. A change in one family member cannot create a change in other members
- C. Individual family members are readily identified as the source of a problem
- D. When the family system is disrupted, change can occur at any point in the system
Correct Answer: D
Rationale: Family systems theory views the family as a whole, where changes in one member affect the entire system, and changes can occur at any point within the system.
The nurse is caring for an adolescent hospitalized for asthma. The adolescent belongs to a large family. The nurse recognizes that the adolescent is likely to relate to which group?
- A. Peers
- B. Parents
- C. Siblings
- D. Teachers
Correct Answer: A
Rationale: Adolescents typically identify and relate more closely to their peer group, especially during the teenage years when peer relationships become a central focus.
The nurse is providing education to the parent of a child with Beta-thalassemia. Which risk factors about the condition should the nurse include in the teaching?
- A. Hypertrophy of the thyroid
- B. Polycythemia vera
- C. Thrombocytopenia
- D. Chronic hypoxia and iron overload
Correct Answer: D
Rationale: The correct answer is D: Chronic hypoxia and iron overload. Children with Beta-thalassemia often suffer from chronic hypoxia due to ineffective erythropoiesis and require frequent blood transfusions, leading to iron overload. These complications must be managed to prevent organ damage. Choices A, B, and C are incorrect. Hypertrophy of the thyroid, polycythemia vera, and thrombocytopenia are not direct risk factors associated with Beta-thalassemia. Therefore, they should not be included in the teaching regarding this condition.
The nurse is planning to counsel family members as a group to assess the family's group dynamics. Which theoretical family model is the nurse using as a framework?
- A. Feminist theory
- B. Family stress theory
- C. Family systems theory
- D. Developmental theory
Correct Answer: C
Rationale: Family systems theory views the family as an interconnected system where changes in one member affect the entire family, making it ideal for assessing group dynamics.