Nokea
Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which of the following clinical finding?
- A. A urine output of 60 mL in 4 hours.
Correct Answer: A
Rationale: urine output of 60 mL in 4 hours is adequate (1 mL/kg/hr for a 15-kg child is 15 mL/hr, or 60 mL in 4 hours). No other findings are provided, so no notification is needed.
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When developing the plan of care for a child who is unconscious after a serious head injury, in which of the following positions should the nurse expect to place the child?
- A. Prone with hips and knees slightly elevated.
- B. Lying on the side, with the head of the bed elevated.
- C. Lying on the back, in the Trendelenburg position.
- D. In the semi-Fowler's position, with arms at the side.
Correct Answer: B
Rationale: Side-lying with the head elevated reduces intracranial pressure and maintains airway patency in an unconscious child.
A nurse is teaching an 8-year-old with diabetes and her parents about managing diabetes during illness. The nurse determines the parents understand the instruction when they indicate that, when the child is ill, they will provide:
- A. More calories.
- B. More insulin.
- C. Less insulin.
- D. Less protein and fat.
Correct Answer: B
Rationale: Illness increases insulin resistance, often requiring more insulin to manage elevated blood glucose. Calorie, protein, or fat adjustments are secondary to insulin needs.
The primary health care provider orders pulse assessments through the night for a 12-year-old child with rheumatic fever who has a daytime heart rate of 120. The nurse explains to the mother that this is to evaluate if the elevated heart rate is caused by:
- A. The morning digitalis.
- B. Normal activity during waking hours.
- C. A warmer daytime environment.
- D. Normal variations in day and evening hours.
Correct Answer: B
Rationale: Elevated heart rate in rheumatic fever may be due to activity, which increases cardiac demand. Nighttime assessments help determine if the rate normalizes at rest, ruling out activity as the cause.
The parent of a child with spastic cerebral palsy and a communication disorder tells the nurse, 'He seems so restless. I think he is in pain.' The nurse should:
- A. Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale.
- B. Assess the child using the pediatric FACES scale.
- C. Administer the pain medication which is ordered to be given as needed and assess the response.
- D. Notify the primary care provider of the change in behavior.
Correct Answer: A
Rationale: The FLACC scale is appropriate for assessing pain in children with communication disorders, as it relies on observable behaviors rather than verbal reports.
A preschooler with pneumococcal meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the needle is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age-group has a need to accomplish which of the following?
- A. Trust those caring for her.
- B. Find diversional activities.
- C. Protect the image of an intact body.
- D. Relieve the anxiety of separation from home.
Correct Answer: C
Rationale: Allowing the child to apply a dressing supports their developmental need to maintain body integrity, reducing anxiety about medical procedures.