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The nurse should refer the parents of an 8-month-old child to a health care provider if the child is unable to:
- A. Stand momentarily without holding onto furniture.
- B. Stand alone well for long periods of time.
- C. Stoop to recover an object.
- D. Sit without support for long periods of time.
Correct Answer: D
Rationale: An 8-month-old should be able to sit without support; inability to do so warrants further evaluation.
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A nurse is assessing the growth and development of a 10-year-old. What is the expected behavior of this child?
- A. Enjoys physical demonstrations of affection.
- B. Is selfish and insensitive to the welfare of others.
- C. Is uncooperative in play and school.
- D. Has a strong sense of justice and fair play.
Correct Answer: D
Rationale: A 10-year-old typically develops a sense of fairness and justice in social interactions.
After teaching the mother of a child with severe burns about the importance of specific nutritional support in burn management, which of the following, if chosen by the mother from the child's diet menu, indicates the need for further teaching?
- A. Bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks.
- B. Cheeseburger, cottage cheese and pineapple salad, chocolate milk, and a brownie.
- C. Chicken nuggets, orange and grapefruit sections, and a vanilla milkshake.
- D. Beef, bean, and cheese burrito; a banana; fruit-flavored yogurt; and skim milk.
Correct Answer: A
Rationale: Burn patients require high-protein, high-calorie diets. Option A is low in protein and calories compared to options B, C, and D, which include protein-rich foods like cheese, chicken, and beans.
A mother asks the nurse if her child's iron deficiency anemia is related to the child's frequent infections. The nurse responds based on the understanding of which of the following?
- A. Little is known about iron deficiency anemia and its relationship to infection.
- B. Children with iron deficiency anemia are more susceptible to infection than are other children.
- C. Children with iron deficiency anemia are less susceptible to infection than are other children.
- D. Children with iron deficiency anemia are equally as susceptible to infection as are other children.
Correct Answer: B
Rationale: Iron deficiency impairs immune function, increasing infection susceptibility. This is well-documented in pediatric care.
The nurse manager on a pediatric floor is reviewing national sentinel event alerts and preparing recommendations for the unit. Which strategy would help reduce pediatric medication errors? Select all that apply.
- A. Eliminate the pediatric satellite pharmacy.
- B. Increase the steps in the medication administration procedure.
- C. Utilize only oral syringes to administer oral medication.
- D. Limit the size of I.V. fluid bags that can be hung on small children.
- E. Reduce the available concentrations or dose strengths to the minimum.
Correct Answer: C,D,E
Rationale: Oral syringes ensure accurate dosing, smaller IV bags prevent fluid overload, and fewer concentrations reduce dosing errors.
After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which of the following?
- A. Inability to extend the fingers on the right hand.
- B. Vomiting after the cast is applied.
- C. Coolness and dampness of the cast after 5 hours.
- D. Fussiness with complaints that the cast is heavy.
Correct Answer: A
Rationale: Inability to extend fingers suggests possible nerve or circulatory compromise, requiring immediate medical attention.