Nokea
When assessing a 4-month-old infant diagnosed with possible intussusception, the nurse should expect the mother to relate which of the following about the infant's crying and episodes of pain?
- A. Constant accompanied by leg extension.
- B. Intermittent with knees drawn to the chest.
- C. Shrill during ingestion of solids.
- D. Intermittent while being held in the mother's arms.
Correct Answer: B
Rationale: Intussusception causes intermittent pain with knees drawn to the chest due to bowel obstruction.
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Which of the following should the nurse include in the postoperative care plan for a child after an appendectomy to promote recovery?
- A. Encourage early ambulation.
- B. Administer laxatives daily.
- C. Keep the child NPO for 48 hours.
- D. Apply a heating pad to the abdomen.
Correct Answer: A
Rationale: Early ambulation prevents complications like atelectasis and promotes recovery.
A nurse is assessing an 8-year-old with diabetes who is experiencing hyperglycemia. Which symptom[s] indicate(s) that the hyperglycemia requires immediate intervention? Select all that apply.
- A. Weakness.
- B. Thirst.
- C. Shakiness.
- D. Hunger.
- E. Headache.
- F. Irritability.
- G. Dizziness.
Correct Answer: B,E,F
Rationale: Thirst, headache, and irritability are hallmark symptoms of hyperglycemia progressing to diabetic ketoacidosis, requiring immediate intervention. Weakness, shakiness, hunger, and dizziness suggest hypoglycemia instead.
Which of the following actions indicates that the parents of a 12-month-old with iron deficiency anemia understand how to administer iron supplements?
- A. They administer iron supplements in combination with fruit juice.
- B. They administer iron supplements with meals.
- C. They report dark stools.
- D. They brush the child's teeth after administering the iron supplements.
- E. They decrease dietary intake of foods fortified with iron.
Correct Answer: A,C,D
Rationale: Iron with fruit juice enhances absorption, dark stools are expected, and brushing teeth prevents staining. Iron with meals reduces absorption, and fortified foods should not be decreased.
When the infant returns to the unit after imperforate anus repair, the nurse should place the infant in which of the following positions?
- A. On the abdomen, with legs pulled up under the body.
- B. On the back, with legs extended straight out.
- C. Lying on the side with the hips elevated.
- D. Lying on the back in a position of comfort.
Correct Answer: C
Rationale: Lying on the side with hips elevated minimizes pressure on the surgical site and promotes healing.
The nurse is assessing a child with sickle cell disease during a routine clinic visit. Which finding requires immediate follow-up by the nurse?
- A. Pallor of the nail beds and mucous membranes.
- B. A heart rate of 88 beats per minute.
- C. Intact and equal bilateral peripheral pulses.
- D. Normal vision and hearing reported by the parents.
Correct Answer: A
Rationale: Pallor of nail beds and mucous membranes indicates anemia or poor perfusion, a serious concern in sickle cell disease requiring immediate follow-up.