Nokea
To assess a 9-year-old's social development, the nurse asks the parent if the child:
- A. Thinks independently.
- B. Is able to organize and plan.
- C. Has a best friend.
- D. Enjoys active play.
Correct Answer: C
Rationale: Having a best friend indicates healthy social development at 9 years.
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A toddler is brought to the emergency room after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which of the following first?
- A. Administering an emetic.
- B. Performing a tracheostomy.
- C. Performing gastric lavage.
- D. Inserting an indwelling urinary (Foley) catheter.
Correct Answer: C
Rationale: Gastric lavage is the priority to remove the corrosive substance from the stomach, preventing further damage. Emetics are contraindicated for corrosives as they can worsen injury. Tracheostomy may be needed later for airway issues, and a urinary catheter is not relevant initially.
The parents of a neonate born with congenital clubfoot express feelings of helplessness and guilt, exhibiting anxiety about how the neonate will be treated. Which of the following actions by the nurse would be most appropriate initially?
- A. Ask them to share these concerns with the physician.
- B. Arrange a meeting with other parents whose infants have clubfoot to discuss their feelings.
- C. Suggest that they make an appointment to talk things over with a counselor.
- D. Encourage the parents to express their feelings and listen attentively.
Correct Answer: D
Rationale: Encouraging expression of feelings and listening attentively is the most appropriate initial step to address emotional concerns and build trust.
Immediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child?
- A. On the back with the head in a position of comfort.
- B. In low Fowler's position with the head turned to the side.
- C. Lying on the abdomen with the head turned to the side.
- D. In reverse Trendelenburg with the head tilted forward.
Correct Answer: C
Rationale: Lying on the abdomen with the head turned to the side facilitates drainage and reduces the risk of aspiration post-surgery.
Which statement by the mother of a child with Wilms' tumor tells the nurse that the mother understands what stage II tumor means?
- A. The tumor has extended beyond the kidney but was completely removed.
- B. Although the tumor was in the kidney, it has spread to the lung, liver, and bone.
- C. The tumor has extended outside the kidney to the lungs and the liver.
- D. The tumor was solely located in the kidney but it was totally removed.
Correct Answer: A
Rationale: Stage II indicates removal beyond kidney.
An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)?
- A. Administering oral medications.
- B. Administering I.V. morphine.
- C. Obtaining vital signs.
- D. Recording the input and output.
- E. Administering blood products.
- F. Morning hygiene.
- G. Circulation checks.
Correct Answer: A,C,D,F,G
Rationale: LPNs can handle oral medications, vital signs, input/output, hygiene, and circulation checks. I.V. morphine and blood products require RN oversight.