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When assessing an infant with an undescended testis, the nurse should be alert for which of the following?
- A. Abnormal lower extremity reflexes.
- B. A history of frequent emesis.
- C. A bulging in the inguinal area.
- D. Poor weight gain.
Correct Answer: C
Rationale: An inguinal bulge may indicate an undescended testis.
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A 12-year-old with rheumatic fever has a history of long-term aspirin use. Which statement by the client indicates that the nurse should notify the health care provider?
- A. I hear ringing in my ears.
- B. Is it alright to put lotion on my itchy skin?
- C. My stomach hurts after I take that medicine.
- D. These pills make me cough.
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of aspirin toxicity, requiring immediate notification. Stomach pain is common but less urgent, and other symptoms are unrelated.
An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. Based on these fi ndings, the nurse should:The chart shows:
- A. Continue monitoring intake and output.
- B. Notify the physician.
- C. Restrict the client’s fluids.
- D. Increase the client’s fluids.
Correct Answer: B
Rationale: The nurse would expect a person with a normal GFR to have approximately equal inputs and outputs. Chronic renal failure has fi ve stages. In stage I the glomerular fi ltration rate (GFR) is approximately ≥90 mL/minute/1.73 m2. In stage II the GFR decreases to approximately 60 to 89 mL/minute/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client’s intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fl uids.
The parents of a neonate born with congenital clubfoot express feelings of helplessness and guilt, exhibiting anxiety about how the neonate will be treated. Which of the following actions by the nurse would be most appropriate initially?
- A. Ask them to share these concerns with the physician.
- B. Arrange a meeting with other parents whose infants have clubfoot to discuss their feelings.
- C. Suggest that they make an appointment to talk things over with a counselor.
- D. Encourage the parents to express their feelings and listen attentively.
Correct Answer: D
Rationale: Encouraging expression of feelings and listening attentively is the most appropriate initial step to address emotional concerns and build trust.
A 10-year-old with glomerulonephritis reports a headache and blurred vision. The nurse should immediately:
- A. Put the client to bed.
- B. Obtain the child's blood pressure.
- C. Notify the physician.
- D. Administer acetaminophen (Tylenol).
Correct Answer: B
Rationale: Symptoms may indicate hypertensive crisis.
A 7-year-old child is experiencing pain after an appendectomy. Which data collection tool should the nurse use to assess the pain?
- A. Visual analog scale.
- B. Short Form McGill Questionnaire.
- C. FACES Pain Rating Scale.
- D. Numeric Pain Intensity Scale.
Correct Answer: C
Rationale: The FACES scale is age-appropriate for a 7-year-old to assess pain.