Nokea
What should the nurse assess in an infant who has been diagnosed with hypertrophic pyloric stenosis?
- A. A history of diarrhea following each feeding
- B. Gastric pain evidenced by vigorous crying
- C. Poor appetite due to a poor sucking reflex
- D. An olive-shaped mass right of the midline
Correct Answer: D
Rationale: Examination of the abdomen may assist in the diagnosis and reveal key signs of hypertrophic pyloric stenosis. Visible peristaltic waves that move from left to right across the epigastric region may be evident, and palpation may reveal an olive-shaped mass in this area to the right of the midline.
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Which is a priority nursing intervention for the cognitively impaired child?
- A. The family will provide good nutrition.
- B. The family will provide loving interactions.
- C. Stimulation will improve.
- D. There will be contact with peers.
Correct Answer: B
Rationale: Nursing interventions focus on promoting optimal development and loving interactions with family.
Parents of a 5-year-old child diagnosed as cognitively impaired have come to the nurse to discuss different approaches to the ongoing care of their child. The nurse should suggest focusing on what activity?
- A. Acquiring job skills
- B. Making decisions
- C. Performing self-care activities
- D. Reading and doing simple math
Correct Answer: C
Rationale: For a cognitively impaired child, focusing on self-care activities supports their development and independence, which is appropriate for a 5-year-old.
Which signs/symptoms would be considered classical signs of meningeal irritation?
- A. Positive Kernig sign, diarrhea, and headache
- B. Negative Brudzinski sign, positive Kernig sign, and irritability
- C. Positive Brudzinski sign, positive Kernig sign, and photophobia
- D. Negative Kernig sign, vomiting, and fever
Correct Answer: C
Rationale: Classical manifestations of meningitis include positive Kernig and Brudzinski signs.
A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion of the nurse is the most appropriate?
- A. Enrolling her in a health club
- B. Taking her to the mall in a wheelchair
- C. Purchasing clothes to disguise the cast
- D. Spending a majority of their time with her
Correct Answer: C
Rationale: The adolescent is trying to fit in with peers and has concerns about body image.
The nurse instructs the parents of a child who has had a myringotomy to place the child in which position?
- A. Supine
- B. On the affected side
- C. On the unaffected side
- D. In a Trendelenburg's position
Correct Answer: B
Rationale: Lying on the affected side facilitates ear drainage following a myringotomy.