Nokea
When checking the intravenous (IV) site on a child, the nurse should take which action?
- A. Look at the site.
- B. Ask the child if the site hurts.
- C. Look at the site while palpating the area.
- D. Take all the tape off, assess the site, and redress.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is assessing a 3-year-old African American child whose height and weight are at the 20th percentile on the growth chart. What should the nurse recognize?
- A. The data suggest the child requires nutritional intervention
- B. The NCHS charts are accurate for U.S. African American children
- C. A correction factor is used for nonwhite ethnic groups
- D. No assessment can be made until several measurements are plotted over time
Correct Answer: B
Rationale: The NCHS growth charts serve as reference guides for all racial or ethnic groups, including African American children. The 20th percentile for height and weight does not indicate nutritional failure but provides a reference point for ongoing assessment. Choice A is incorrect because being at the 20th percentile does not automatically imply the need for nutritional intervention. Choice C is incorrect as there is no correction factor specifically used for nonwhite ethnic groups in this context. Choice D is incorrect as a single measurement at the 20th percentile can provide valuable information for assessment.
What clinical manifestation(s) is associated with calcium depletion (hypocalcemia)?
- A. Nausea, vomiting
- B. Weakness, fatigue
- C. Muscle hypotonicity
- D. Neuromuscular irritability
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A parent brings their 2-year-old son in for a well visit. The nurse assesses his growth since the last appointment. Which finding should concern the nurse?
- A. Prominent abdomen
- B. Forward curve of the spine in the sacral area
- C. Increase in height of 5 inches in the past year
- D. Total weight gain of 15 lb in the past year
Correct Answer: D
Rationale: The correct answer is D. A total weight gain of 15 lb in one year for a 2-year-old is excessive and may indicate an underlying issue such as a metabolic disorder or overfeeding. This rapid weight gain can put the child at risk for health problems. Choices A, B, and C are not typically concerning findings in a 2-year-old. A prominent abdomen can be normal at this age due to a toddler's slightly protruding belly, a forward curve of the spine at the sacral area is a typical finding in young children, and an increase in height of 5 inches in a year is within the expected range of growth for a 2-year-old.
A child with acetaminophen (Tylenol) poisoning has been admitted to the emergency department. What antidote does the nurse anticipate being prescribed?
- A. Carnitine (Carnitor)
- B. Fomepizole (Antizol)
- C. Deferoxamine (Desferal)
- D. N-acetylcysteine (Mucomyst)
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse has completed an education program on normal communication abilities in the preschool-age child. Which statement by a participant indicates a need for further education?
- A. When my child counts numbers, it is only to 10 and we are slowly working on counting higher.
- B. I am glad to know that my 4-year-old child asking so many questions is normal.
- C. Stating his name and address is too hard for my 5-year-old child; it will be another year before he can do that.
- D. My child is finally talking in a way that most of my friends can understand her speech.
Correct Answer: C
Rationale: The correct answer is C. By age 5, children should be able to state their name and address. If a child cannot do this, it may indicate a developmental delay that requires further assessment. Choices A, B, and D do not indicate a need for further education as they reflect typical developmental milestones for preschool-age children, such as gradually improving counting skills, asking many questions, and improving speech clarity over time.