Nokea
The practical nurse is providing care for a toddler who has just returned from surgery for a tonsillectomy. Which intervention is a priority in the immediate postoperative period?
- A. Offer clear fluids frequently.
- B. Encourage the child to cough and deep breathe.
- C. Monitor for frequent swallowing.
- D. Apply a warm compress to the throat area.
Correct Answer: C
Rationale: Monitoring for frequent swallowing is a priority intervention in the immediate postoperative period after a tonsillectomy. Frequent swallowing may indicate bleeding from the surgical site, which requires immediate attention to prevent complications such as hemorrhage. Offering clear fluids frequently may not be appropriate immediately after surgery. Encouraging coughing and deep breathing may increase the risk of bleeding. Applying a warm compress to the throat area is not recommended as it can increase blood flow to the surgical site, potentially causing bleeding.
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The nurse provides information about the human papillomavirus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?
- A. Use of protective barriers during sexual activity prevents most strains of HPV infection
- B. Most adolescents are not honest about being sexually active
- C. Not all strains of HPV will be covered if given at a later date
- D. Immunity must be established to prevent future HPV infection and the risk for cervical cancer
Correct Answer: D
Rationale: Administering the HPV vaccine at this visit is essential to establish immunity against HPV, thus reducing the risk of HPV infection and cervical cancer. Vaccination is a proactive measure to protect the adolescent's health in the future. Choice A is incorrect because although protective barriers can reduce the risk of HPV transmission, the vaccine provides broader protection. Choice B is incorrect as it makes a generalization about adolescent behavior that is not relevant to vaccination. Choice C is incorrect as it suggests that delaying vaccination would not impact coverage, which is inaccurate as earlier vaccination provides broader protection against HPV strains.
When caring for a child with Kawasaki disease, which symptom is the most significant for making this diagnosis?
- A. Desquamation of the palms and soles.
- B. Cervical lymphadenopathy.
- C. Erythema of the hands and feet.
- D. Strawberry tongue.
Correct Answer: C
Rationale: Erythema of the hands and feet is a key diagnostic criterion for Kawasaki disease. This, along with other symptoms like fever and strawberry tongue, helps in making the diagnosis. While desquamation of the palms and soles, cervical lymphadenopathy, and strawberry tongue are associated with Kawasaki disease, the presence of erythema of the hands and feet is particularly significant in diagnosing this condition.
When should a mother introduce solid foods to her 4-month-old infant? The mother states that her mother suggests putting rice cereal in the baby's bottle. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry
- B. Opens mouth when food is offered
- C. Awakens once for nighttime feedings
- D. Gives up a bottle for a cup
Correct Answer: B
Rationale: Introducing solid foods when the child opens their mouth for food is important to ensure readiness for solids. This behavior indicates the infant's interest and readiness for new textures and flavors, promoting safe and successful introduction to solid foods. The other choices are not indicative of the infant's readiness for solid foods: A - stopping rooting is a reflex action, C - awakening for nighttime feedings is a normal behavior, and D - transitioning from a bottle to a cup is a developmental milestone unrelated to solid food introduction.
While assessing the vital signs of a 10-year-old who underwent a tonsillectomy this morning, the nurse observes the child swallowing every 2-3 minutes. Which assessment should the nurse implement?
- A. Inspect the posterior oropharynx
- B. Assess for teeth clenching or grinding
- C. Touch the tonsillar pillars to stimulate the gag reflex
- D. Ask the child to speak to evaluate a change in voice tone
Correct Answer: A
Rationale: Frequent swallowing post-tonsillectomy may indicate bleeding. Inspecting the posterior oropharynx is essential to assess for any signs of bleeding, such as fresh blood or clots, which may necessitate immediate intervention. Option B is incorrect as teeth clenching or grinding is not directly related to the observation of frequent swallowing in this scenario. Option C is incorrect because stimulating the gag reflex is not necessary at this point and may be uncomfortable for the child. Option D is incorrect as evaluating a change in voice tone is not relevant to the situation of observing frequent swallowing.
The healthcare provider is evaluating diet teaching for a client who has nontropical sprue (celiac disease). Choosing which food indicates that the teaching has been effective?
- A. Creamed corn.
- B. Pancakes.
- C. Rye crackers.
- D. Cooked oatmeal.
Correct Answer: A
Rationale: Creamed corn is a gluten-free food, making it a suitable option for clients with celiac disease. This choice indicates effective diet teaching as it aligns with the dietary restrictions necessary for managing the condition. Pancakes, rye crackers, and cooked oatmeal contain gluten, which is harmful to individuals with celiac disease. Therefore, they are not suitable choices and would not indicate effective teaching for a client with this condition.