Nokea
The practical nurse is caring for a child with suspected appendicitis. Which assessment finding should be reported to the healthcare provider immediately?
- A. Nausea and vomiting.
- B. Sudden relief of pain.
- C. Low-grade fever.
- D. Rebound tenderness.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A mother brings her 3-week-old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life-threatening complication?
- A. Irregular palpable pulse
- B. Hyperactive bowel sounds
- C. Underweight for age
- D. Crying without tears
Correct Answer: D
Rationale: Crying without tears is a sign of severe dehydration, which is a potentially life-threatening complication in infants with projectile vomiting. Dehydration can rapidly progress in infants, leading to serious consequences if not promptly addressed. The combination of projectile vomiting, listlessness, and absence of tears when crying should raise concerns about severe dehydration and the need for urgent intervention to prevent further complications.
An 8-year-old male client with nephrotic syndrome is receiving salt-poor human albumin IV. Which findings indicate to the nurse that the child is manifesting a therapeutic response?
- A. Decreased urinary output
- B. Decreased periorbital edema
- C. Increased periods of rest
- D. Weight gain of 0.5 kg/day
Correct Answer: B
Rationale: In nephrotic syndrome treatment, decreased periorbital edema is a positive therapeutic response as it indicates a reduction in fluid retention. Periorbital edema is a common symptom of nephrotic syndrome due to fluid accumulation, so a decrease in this swelling signifies an improvement in the condition.
After observing a mother giving her 11-month-old ferrous sulfate followed by two ounces of orange juice, what should the nurse do next?
- A. Suggest placing the iron drops in the orange juice and feed the infant.
- B. Advise the mother to follow the iron drops with formula instead of orange juice.
- C. Instruct the mother to feed the infant nothing in the next 30 minutes after the iron.
- D. Give positive feedback about the way she administered the sulfate.
Correct Answer: D
Rationale: Providing positive feedback is essential in reinforcing correct behaviors. By praising the mother for properly administering the ferrous sulfate to her 11-month-old, the nurse can encourage her to continue following the correct procedure. This positive reinforcement can boost the mother's confidence and adherence to the recommended administration method, ultimately benefiting the infant's health.
Why is honest information important in building a trusting relationship with adolescent patients?
- A. Encourage the adolescent to seek help outside of the school clinic.
- B. Keep disclosures from the adolescent confidential.
- C. Honest information ensures establishing a trusting relationship.
- D. Discourage minor adolescents from disclosing private concerns.
Correct Answer: C
Rationale: Honesty is fundamental in building trust with adolescent patients as it helps create an environment where they feel safe to share their concerns openly. By being honest and maintaining confidentiality, healthcare providers can establish a strong and trusting relationship with adolescents, ultimately leading to better healthcare outcomes.
An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test that was drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?
- A. Ask when the adolescent was last seen in the clinic
- B. Tell the mother to have the teenager call the clinic
- C. Since the serum sample was drawn last week, provide the mother with the findings
- D. Explain that the information cannot be released without the 18-year-old's permission
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.