What is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child?
- A. Rinne test
- B. Weber test
- C. Pure tone audiometry
- D. Eliciting the startle reflex
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large and one is too small. The best nursing action is which?
- A. Use the small cuff
- B. Use the large cuff
- C. Use either cuff using the palpation method
- D. Wait to take the blood pressure until a proper cuff can be located
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of a child with sickle cell anemia ask why their child did not have a sickle cell crisis until he was approximately 6 months old. How should the nurse respond?
- A. Your child probably had a crisis, and you were unaware of the symptoms.
- B. Are you sure your child has sickle cell anemia and not sickle cell trait?
- C. Affected children can be asymptomatic in early infancy because of high levels of fetal hemoglobin that inhibit sickling.
- D. Have you asked your doctor about this yet?
Correct Answer: C
Rationale: The correct answer is C. Fetal hemoglobin (HbF) is present in high levels during early infancy, inhibiting sickling unlike adult hemoglobin (HbS). As the levels of HbF decrease and HbS increases, the risk of sickling and crises becomes more pronounced, typically after 6 months of age. Choice A is incorrect because it assumes the crisis went unnoticed, which is not supported by medical knowledge. Choice B is incorrect as it questions the child's diagnosis rather than explaining the phenomenon of delayed crises. Choice D is incorrect as it does not provide the parents with the necessary information regarding their query.
An infant is born with anencephaly. Based on the knowledge of this diagnosis, what information does the nurse consider when interacting with the family?
- A. Many treatment options exist.
- B. Immediate surgery is necessary.
- C. The condition is incompatible with life.
- D. The child will have permanent disabilities.
Correct Answer: C
Rationale: The correct answer is C: 'The condition is incompatible with life.' Anencephaly is the most serious neural tube defect where both hemispheres of the brain are absent. It is incompatible with life, as there are no medical or surgical treatment options available. While some infants with mature brain stem function can maintain vital functions for a short period, anencephaly is ultimately not survivable. Choice A is incorrect as there are no treatment options for anencephaly. Choice B is incorrect as immediate surgery is not necessary for this condition. Choice D is incorrect as an infant with anencephaly will not have permanent disabilities since the condition is not compatible with life.
A child is admitted with suspected pyloric stenosis. Which of the following should be included in the plan of care?
- A. Monitor for signs of metabolic acidosis
- B. Observe for projectile vomiting
- C. Provide large, infrequent feedings to allow for rest
- D. Place the infant in a supine position after feeding
Correct Answer: B
Rationale: The correct answer is B: 'Observe for projectile vomiting.' Projectile vomiting is a classic sign of pyloric stenosis, caused by obstruction at the pylorus. Choice A is incorrect as metabolic alkalosis, not acidosis, often occurs due to the loss of hydrochloric acid from persistent vomiting. Choice C is incorrect as frequent, small feedings are preferred to prevent overloading the stomach. Choice D is incorrect as placing the infant in an upright position after feeding can help reduce reflux.
The mother of an infant diagnosed with bronchiolitis asks the nurse what causes the disease. How should the nurse respond?
- A. Respiratory syncytial virus (RSV)
- B. Haemophilus influenzae
- C. Parainfluenza
- D. Rotavirus
Correct Answer: A
Rationale: The correct answer is A: Respiratory syncytial virus (RSV). RSV is the most common cause of bronchiolitis, especially in infants. Bronchiolitis is characterized by inflammation of the small airways in the lungs. Choice B, Haemophilus influenzae, is a bacterium that can cause respiratory infections but is not the primary cause of bronchiolitis. Choice C, Parainfluenza, is a common viral infection that can cause croup and other respiratory illnesses but is not the main cause of bronchiolitis. Choice D, Rotavirus, is a virus that primarily affects the gastrointestinal system, causing diarrhea and vomiting, and is not associated with bronchiolitis.