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When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: Bending forward at the waist with arms hanging freely allows the nurse to observe for spinal asymmetry, a key sign of scoliosis.
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During physical assessment of a 4-month-old infant with Hirschsprung's disease, the nurse should most likely note which of the following?
- A. Scaphoid-shaped abdomen.
- B. Weight less than expected for height and age.
- C. Cyanosis of the fingers and toes.
- D. Hyperactive deep tendon reflexes.
Correct Answer: B
Rationale: Hirschsprung's disease can lead to poor weight gain due to bowel obstruction.
Which of the following measures would be most effective in helping the infant with a cleft lip and palate to retain oral feedings?
- A. Burp the infant at frequent intervals.
- B. Feed the infant small amounts at one time.
- C. Place the end of the nipple far to the back of the infant's tongue.
- D. Maintain the infant in a lying position while feeding.
Correct Answer: B
Rationale: Feeding small amounts at a time reduces the risk of aspiration and helps the infant manage feedings despite the cleft, promoting retention.
The physician orders an intravenous infusion of 5% dextrose in 0.25 normal saline to be infused at 2 mL/kg/hour in an infant who weighs 9 lb. How many milliliters per hour of the solution should the nurse infuse? Round to one decimal.
- A. 8.2 mL/hour
- B. 9.0 mL/hour
- C. 7.4 mL/hour
- D. 6.8 mL/hour
Correct Answer: A
Rationale: 9 lb = 4.08 kg; 2 mL/kg/hour × 4.08 kg = 8.16 mL/hour, rounded to 8.2.
The nurse observes as a child with Duchenne's muscular dystrophy attempts to use from a sitting position on the floor. After attaining a kneeling position, the child 'walks' his hands up his legs to stand. The nurse documents this as which of the following?
- A. Galeazzi's sign.
- B. Goodell's sign.
- C. Goodenough's sign.
- D. Gower's sign.
Correct Answer: D
Rationale: Gower's sign is characteristic of Duchenne's muscular dystrophy, indicating proximal muscle weakness as the child uses their hands to 'walk' up their legs to stand.
After doing well for a period of time, a child with leukemia develops an overwhelming infection. The child's death is imminent. Which of the following statements offers the nurse the best guide in making plans to assist the parents in dealing with their child's imminent death?
- A. Knowing that the prognosis is poor helps prepare relatives for the death of children.
- B. Relatives are especially grieved when a child does well at first but then declines rapidly.
- C. Trust in health care personnel is most often destroyed by a death that is considered untimely.
- D. It is more difficult for relatives to accept the death of an older child than that of a toddler.
Correct Answer: B
Rationale: A rapid decline after improvement is particularly devastating, guiding the nurse to provide extra emotional support.