Nokea
The nurse is teaching the parents of a child with leukemia about infection prevention. Which instruction should the nurse include?
- A. Encourage frequent handwashing.
- B. Allow the child to attend crowded events.
- C. Administer live vaccines as scheduled.
- D. Avoid fresh fruits and vegetables.
Correct Answer: A
Rationale: Frequent handwashing is critical to prevent infections in leukemia, as the child is immunocompromised. Crowded events, live vaccines, and raw produce increase infection risk.
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Which of the following actions indicates that the parents of a 12-month-old with iron deficiency anemia understand how to administer iron supplements?
- A. They administer iron supplements in combination with fruit juice.
- B. They administer iron supplements with meals.
- C. They report dark stools.
- D. They brush the child's teeth after administering the iron supplements.
- E. They decrease dietary intake of foods fortified with iron.
Correct Answer: A,C,D
Rationale: Iron with fruit juice enhances absorption, dark stools are expected, and brushing teeth prevents staining. Iron with meals reduces absorption, and fortified foods should not be decreased.
When positioning a neonate with an unrepaired myelomeningocele, which of the following positions is most appropriate?
- A. Supine with the hips at 90-degree flexion.
- B. Right side-lying position with the knees flexed.
- C. Prone with hips in abduction.
- D. Supine in semi-Fowler's position with chest and abdomen elevated.
Correct Answer: C
Rationale: The prone position protects the myelomeningocele sac from pressure and rupture before surgical repair, with hips in abduction to maintain alignment and prevent strain on the defect.
The mother asks the nurse whether her child with hemiparesis due to spastic cerebral palsy will be able to walk normally because he can pull himself to a standing position. Which of the following responses by the nurse would be most appropriate?
- A. Ask the doctor what he thinks at your next appointment.'
- B. Maybe, maybe not. How old were you when you first walked?'
- C. It's difficult to predict, but his ability to bear weight is a positive factor.'
- D. If he really wants to walk, and works hard, he probably will eventually.'
Correct Answer: C
Rationale: The ability to bear weight is a positive sign, but predicting normal walking is challenging due to the variability in cerebral palsy outcomes.
Which of the following is appropriate language development for an 8-month-old? The child should be:
- A. Saying 'dada' and 'mama' specifically ('dada' to father and 'mama' to mother).
- B. Saying three other words besides 'mama' and 'dada.'
- C. Saying 'dada' and 'mama' nonspecifically.
- D. Saying 'ball' when parents point to a ball.
Correct Answer: C
Rationale: At 8 months, infants typically say 'dada' and 'mama' nonspecifically, as specific use develops closer to 12 months.
A nurse is assessing an 8-year-old with diabetes who is experiencing hyperglycemia. Which symptom[s] indicate(s) that the hyperglycemia requires immediate intervention? Select all that apply.
- A. Weakness.
- B. Thirst.
- C. Shakiness.
- D. Hunger.
- E. Headache.
- F. Irritability.
- G. Dizziness.
Correct Answer: B,E,F
Rationale: Thirst, headache, and irritability are hallmark symptoms of hyperglycemia progressing to diabetic ketoacidosis, requiring immediate intervention. Weakness, shakiness, hunger, and dizziness suggest hypoglycemia instead.