Nokea
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:
- A. Keep their home warmer than usual.
- B. Encourage twenty or outdoor activities.
- C. Promote interactions with one friend instead of groups.
- D. Limit bathing to prevent skin irritation.
Correct Answer: C
Rationale: Hyperthyroidism causes irritability and hyperactivity, so limiting social interactions to one friend reduces overstimulation. Warmer homes, excessive activity, and limited bathing are inappropriate.
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When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of which of the following foods indicates a need for further teaching?
- A. Low-protein bread.
- B. Special PKU formula.
- C. Fresh apples.
- D. Chicken nuggets.
Correct Answer: D
Rationale: Chicken nuggets are high in phenylalanine, contraindicated in PKU. Low-protein bread, PKU formula, and apples are appropriate for a PKU diet.
When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which of the following possible sources of infection?
- A. Nonrefrigerated custard.
- B. A pet canary.
- C. Undercooked eggs.
- D. Unwashed fruit.
Correct Answer: C
Rationale: Undercooked eggs are a common source of Salmonella infection.
Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
- A. Hemorrhagic skin rash.
- B. Edema.
- C. Cyanosis.
- D. Dyspnea on exertion.
Correct Answer: A
Rationale: A hemorrhagic rash, such as petechiae or purpura, is a hallmark of disseminated intravascular coagulation in meningitis, indicating clotting abnormalities.
The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani’s “click.”
- B. Limited abduction.
- C. Galeazzi’s sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: This infant with congenital hip dysplasia has asymmetric gluteal folds. The Ortolani “click” occurs when the nurse feels the femur sliding into the acetabulum with a “click.” Limited abduction may be observed during an attempt to abduct the infant’s thighs. Galeazzi’s sign reveals femoral foreshortening and is observed by fl exing the thighs.
The nurse reads the new medications orders for a 4-year-old child with nephrotic syndrome on the chart below: Orders D/C prednisolone 40 mg PO Daily Prednisolone 30 mg PO QOD The nurse should:
- A. Discontinue the prednisolone 40 mg and give the 30 mg dose today.
- B. Check the medication record first to see when the last dose of prednisolone was given.
- C. Start the 30 mg dose tomorrow.
- D. Contact the prescriber for clarification.
Correct Answer: D
Rationale: Clarification ensures correct dosing.