Nokea
The nurse should monitor the child for which of the following complications?
- A. Nuchal rigidity when standing
- B. Double vision
- C. Headache
- D. Pain in the posterior iliac crest
Correct Answer: C
Rationale: The correct answer is C: Headache. In pediatric patients, headaches can be indicative of serious underlying conditions such as meningitis or increased intracranial pressure. Monitoring for headaches is crucial for early detection and intervention. Nuchal rigidity when standing (A) is more indicative of meningitis in adults. Double vision (B) is more associated with neurological issues. Pain in the posterior iliac crest (D) is not typically a complication that requires monitoring in children.
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Which of the following findings should the nurse report to the provider?
- A. Unable to roll from back to abdomen
- B. Exhibits head lag when pulled to a sitting position
- C. Unable to hold a bottle
- D. Absent grasp reflex
Correct Answer: B
Rationale: The correct answer is B: Exhibits head lag when pulled to a sitting position. This finding indicates poor head control, a developmental milestone typically achieved around 4 months. Reporting this to the provider is crucial for further assessment and intervention. Choice A is incorrect as rolling from back to abdomen is typically achieved around 5-6 months. Choice C is incorrect as holding a bottle is a milestone around 6-10 months. Choice D is incorrect as the grasp reflex typically disappears around 3-4 months. The key is to identify the finding that deviates significantly from the expected developmental milestone, which is demonstrated by choice B.
Which of the following actions should the nurse take first?
- A. Obtain an x-ray of the child's neck.
- B. Administer intravenous antibiotics.
- C. Initiate droplet precautions.
- D. Place intubation equipment at the bedside.
Correct Answer: D
Rationale: The correct action for the nurse to take first is to place intubation equipment at the bedside (Choice D). This is crucial in case the child's condition deteriorates rapidly and respiratory support is needed. Placing the intubation equipment ensures immediate access to airway management, which takes precedence over other actions. Obtaining an x-ray may provide diagnostic information but is not as urgent as ensuring airway patency. Administering antibiotics and initiating droplet precautions (Choice C) are important but not the immediate priority in this scenario. Therefore, Choice D is the correct first action to ensure the child's safety and optimal care.
Which of the following actions should the nurse take?
- A. Inform the client to contact the pharmacy regarding any questions related to the medication.
- B. Provide instructions to the client's parent with the client present.
- C. Instruct the client's parents to write down the information that is being provided.
- D. Ask how the client prefers to learn new information.
Correct Answer: D
Rationale: The correct answer is D: Ask how the client prefers to learn new information. This action is client-centered and promotes individualized care by understanding the client's preferred learning style. It helps tailor the teaching approach to best meet the client's needs, leading to improved understanding and compliance.
Choice A is incorrect because the nurse should provide medication information directly to the client instead of redirecting to the pharmacy.
Choice B is incorrect as it does not involve the client in the learning process, which is essential for effective education.
Choice C is incorrect as it focuses on the parents rather than the client, missing the opportunity to engage the client directly.
Overall, choice D stands out for its client-focused approach, making it the most appropriate action in this scenario.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child might experience mood swings.
- B. I should take my child to the clinic for a weekly blood test.
- C. I should withhold my child's medication before physical activity.
- D. My child might have a decreased appetite.
Correct Answer: A
Rationale: The correct answer is A: "My child might experience mood swings." This statement shows understanding as mood swings can be a side effect of the medication being discussed. It demonstrates awareness of potential effects and indicates readiness to handle them. Choice B is incorrect as weekly blood tests are not typically necessary. Choice C is incorrect as withholding medication before physical activity can be dangerous. Choice D is incorrect as a decreased appetite is not a common side effect.
For which of the following adverse effects should the nurse monitor?
- A. Hypotension
- B. Prolonged wound healing
- C. Stevens-Johnson syndrome
- D. Bradypnea
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. This is a severe adverse reaction characterized by blistering and peeling of the skin, mucous membranes involvement, and flu-like symptoms. It is potentially life-threatening and requires immediate medical intervention. The nurse should monitor for early signs such as rash, fever, and mucosal lesions. Choices A, B, and D are not typically associated with the medication's adverse effects. Hypotension is a common side effect of some medications but not the focus of monitoring for this specific drug. Prolonged wound healing is more related to factors like nutrition and comorbidities. Bradypnea (slow breathing) is not commonly associated with adverse effects of medications but could signify respiratory distress.