Nokea
When caring for an infant post-repair of an anorectal malformation, which of the following should the nurse monitor to prevent complications?
- A. Skin integrity around the surgical site.
- B. Frequency of oral feedings.
- C. Daily weight gain.
- D. Parental bonding behaviors.
Correct Answer: A
Rationale: Monitoring skin integrity prevents infection and breakdown at the surgical site.
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Which complication is the nurse most concerned about in an obese child?
- A. Asthma.
- B. Type 2 diabetes.
- C. Seasonal allergies.
- D. Iron deficiency.
Correct Answer: B
Rationale: Obesity increases the risk of type 2 diabetes due to insulin resistance. Asthma and allergies may occur, but diabetes is a more significant concern. Iron deficiency is unrelated.
The parent of a 17-year-old boy, who is hospitalized for complications related to type I diabetes, requests to review the adolescent's medical record. The client reported receiving mental health counseling during the admission history, but did not want his parent to know. The nurse, who is uncertain of how to protect the adolescent's privacy and accommodate the parent's request, should consult:
- A. The unit nurse manager.
- B. The primary care provider.
- C. The organization's privacy officer.
- D. The customer service representative.
Correct Answer: C
Rationale: The privacy officer is trained to handle HIPAA and confidentiality issues, ensuring the adolescent's privacy (e.g., mental health records) is protected while addressing parental rights.
When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis?
- A. Where did the pain start?
- B. What did you do for the pain?
- C. How often do you have a bowel movement?
- D. Is the pain continuous, or does it let up?
Correct Answer: A
Rationale: Pain starting near the umbilicus and migrating to the right lower quadrant is characteristic of appendicitis.
After having a blood sample drawn, a 5-year-old child insists that the site be covered with a bandage. When the parent tries to remove the bandage before leaving the office, the child screams that all the blood will come out. The nurse encourages the parent to leave the bandage in place and tells the parent that the child:
- A. Fears another procedure.
- B. Does not understand body integrity.
- C. Is expressing pain.
- D. Is attempting to regain control.
Correct Answer: B
Rationale: Preschoolers may fear loss of body integrity, believing blood will leak out without a bandage.
The nurse is monitoring an infant receiving IV fluids for gastroenteritis. Which finding suggests the infant is responding well to treatment?
- A. Dry mucous membranes.
- B. Weight gain of 50 grams daily.
- C. Urine output of 1 mL/kg/hour.
- D. Heart rate of 180 bpm.
Correct Answer: C
Rationale: Adequate urine output indicates effective rehydration.