Nokea
What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?
- A. The medication should be given on an empty stomach.
- B. Insomnia can be a significant side effect.
- C. Gums should be massaged regularly to prevent hyperplasia.
- D. Blood pressure should be closely monitored.
Correct Answer: C
Rationale: Dilantin can cause gum overgrowth, which can be minimized by regular massaging.
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The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?
- A. Athetoid
- B. Ataxic
- C. Spastic
- D. Mixed
Correct Answer: C
Rationale: Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.
What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?
- A. Use gestures and signs as much as possible.
- B. Let the child's parents communicate for her.
- C. Face the child and speak clearly in short sentences.
- D. Recognize that the child's ability to communicate will be on a 6-year-old child's level.
Correct Answer: C
Rationale: The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.
Which situation would cause the nurse to suspect a hearing impairment?
- A. 3-month-old infant with a positive Moro (startle reaction) reflex
- B. 15-month-old toddler who is babbling
- C. 18-month-old toddler who is speaking one-syllable words
- D. 24-month-old toddler who communicates by pointing
Correct Answer: D
Rationale: The child who is not making verbal attempts by 24 months should undergo a complete physical examination.
A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion?
- A. Sleepy but easily arousable
- B. Complaining of a stiff neck
- C. Cannot remember what happened to him
- D. Pupils react sluggishly to light
Correct Answer: C
Rationale: A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness, often accompanied by a loss of memory of the events.
Which aspect(s) of a child's development does the nurse caution parents that hearing impairment can affect? (Select all that apply.)
- A. Speech clarity
- B. Language development
- C. Immunity to disease
- D. Personality development
- E. Academic achievement
Correct Answer: A,B,D,E
Rationale: All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.