Nokea
What should be part of the nurse's teaching plan for a child with epilepsy being discharged on a regimen of diphenylhydantoin (Dilantin)?
- A. Drinking plenty of fluids.
- B. Brushing teeth after each meal.
- C. Having someone be with the child during waking hours.
- D. Reporting signs of infection.
Correct Answer: B
Rationale: Dilantin can cause gingival hyperplasia; brushing after meals promotes oral hygiene to mitigate this side effect.
You may also like to solve these questions
When providing intermittent nasogastric feedings to an infant with failure to thrive, which method is preferred to confirm tube placement before each feeding?
- A. Obtain a chest X-ray.
- B. Verify that the gastric pH is less than 5.5.
- C. Auscultate the stomach while instilling an air bolus.
- D. Compare the tube insertion length to a standardized chart.
Correct Answer: B
Rationale: Gastric pH <5.5 confirms stomach placement non-invasively. X-rays are impractical for each feeding, auscultation is unreliable, and length comparison doesn't verify placement.
The nurse should refer the parents of an 8-month-old child to a health care provider if the child is unable to:
- A. Stand momentarily without holding onto furniture.
- B. Stand alone well for long periods of time.
- C. Stoop to recover an object.
- D. Sit without support for long periods of time.
Correct Answer: D
Rationale: An 8-month-old should be able to sit without support; inability to do so warrants further evaluation.
A 10-year-old with scoliosis has to wear a brace. The nurse should develop a teaching plan with the client to include which of the following instructions?
- A. Wear the brace during waking hours.
- B. Wear the brace only during sleep.
- C. Wear a form-fitting, sleeveless T-shirt under the brace.
- D. Bathe the skin under the brace once per week.
Correct Answer: A,C
Rationale: The brace should be worn during waking hours for maximum effectiveness, and a form-fitting T-shirt helps protect the skin and improve comfort.
The nurse identifies a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure for a school-age child scheduled for a tonsillectomy. Which of the following is an expected outcome for this nursing diagnosis?
- A. The child is able to tell about the surgery and recovery.
- B. The child remains on nothing-by-mouth (NPO) status for the designated preoperative period.
- C. The child and family demonstrate an understanding of the procedure.
- D. The child knows the parents will not leave.
Correct Answer: B
Rationale: The most appropriate outcome for a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure should be that the child remains NPO for the designated period of time before surgery, thereby minimizing the risk of aspiration during the surgery. Ability to tell about the surgery and demonstrating an understanding of the procedure are appropriate outcomes for a nursing diagnosis of Deficient knowledge. Knowing that the parents will not leave is associated with a nursing diagnosis of Anxiety or Fear related to separation from support systems or an unfamiliar environment.
A 2-year-old tells his mother he is afraid to go to sleep because 'the monsters will get him.' The nurse should tell his mother to:
- A. Allow him to sleep with his parents in their bed whenever he is afraid.
- B. Increase his activity before he goes to bed, so he eventually falls asleep from being tired.
- C. Give him a favorite cuddly animal or a blanket.
- D. Allow him to stay up an hour later with the family until he falls asleep.
Correct Answer: C
Rationale: A comfort object helps a toddler feel secure and supports self-soothing.