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The parents of a child who is diagnosed with Wilm's tumor ask the nurse why surgery is necessary before a biopsy is performed. What information should the nurse provide?
- A. The surgery provides a visualization of other pathology and dysfunction of the kidney.
- B. Surgery is necessary to stage the tumor and determine metastasis to other sites.
- C. Metal clips are surgically applied at the tumor site for exact marking for radiation.
- D. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread.
Correct Answer: D
Rationale: Biopsy risks rupturing the tumor, potentially spreading cancer cells.
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The parents of a 14-month-old child, hospitalized due to febrile seizures, express their concern to the nurse about their child having seizures for life. What information should the nurse share with these parents?
- A. Avoid overstimulation as it can trigger seizure activity.
- B. Assure the parents that the frequency of febrile seizures decreases as the child ages.
- C. Suggest giving the child a sponge bath when the temperature exceeds 100.6°F (38.1°C).
- D. Advise the prophylactic use of Ibuprofen to prevent febrile seizures.
Correct Answer: B
Rationale: Febrile seizures typically decrease with age, often resolving by age 5.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Recognizes most letters and numbers.
- B. Uses 1-word sentences.
- C. Speaks in simple sentences with four or more words.
- D. Uses gestures with 1 to 2-word sentences.
Correct Answer: C
Rationale: Speaking in simple sentences with four or more words is a normal milestone for a 3-year-old.
A mother brings her 2-month-old to the well-baby clinic. She mentions that when she kisses her baby, the infant's skin tastes salty. What standard diagnostic test should the nurse prepare the mother for to screen for cystic fibrosis (CF)?
- A. Fecal-fat test.
- B. Sweat-chloride test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: B
Rationale: The sweat-chloride test is the standard diagnostic for cystic fibrosis, detecting elevated chloride levels.
The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure. The infant's vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute. Which medication should the nurse hold and inform the health care provider?
- A. Enalapril
- B. Digoxin
- C. Furosemide
- D. Hydralazine
Correct Answer: B
Rationale: The infant's apical pulse of 88 beats/minute is below the normal range (100-160 beats/minute) for an eight-month-old, indicating a need to hold Digoxin and notify the provider.
The nurse is monitoring a child with hydrocephalus who received a ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement
- B. The child reports no evidence of continuous headaches
- C. An intracranial pressure (ICP) monitoring probe is in place
- D. The child is afebrile with normal vital signs postoperatively.
Correct Answer: B
Rationale: Absence of continuous headaches indicates the shunt is relieving brain pressure effectively.