Nokea
When developing a teaching plan for the mother of an asthmatic child concerning measures to reduce allergic triggers, which of the following suggestions should the nurse include:
- A. Keep the humidity in the home between 50% and 60%.
- B. Have the child sleep in the bottom bunk bed.
- C. Use a scented room deodorizer to keep the room fresh.
- D. Vacuum the carpet once or twice a week.
Correct Answer: C
Rationale: Using a scented room deodorizer can irritate airways and trigger asthma symptoms. The nurse should advise against this to reduce allergic triggers, while recommending measures like dust mite control and avoiding strong odors.
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A nurse is assessing an infant with failure to thrive. Which finding requires immediate intervention?
- A. Weight below 5th percentile.
- B. Heart rate of 180 bpm.
- C. Poor feeding for 1 week.
- D. Dry mucous membranes.
Correct Answer: B
Rationale: A heart rate of 180 bpm suggests distress (e.g., dehydration, sepsis), requiring urgent evaluation. Low weight, poor feeding, and dry membranes are concerning but less acute.
After teaching the mother of a neonate who has successfully undergone surgery to repair a low anorectal anomaly, the mother indicates that she understands her child's prognosis when she states which of the following?
- A. My child will need to wear protective pads until puberty.
- B. My child will need extra fluids to prevent constipation.
- C. My child will probably always need a high-fiber diet.
- D. My child has a good chance of being potty trained.
Correct Answer: D
Rationale: Low anorectal anomalies often have a good prognosis for continence with proper management.
An 8-year-old child does well after infratentorial tumor removal and is transferred back to the pediatric unit. Although she had been told about having her head shaved, she becomes upset. After exploring the child's feelings, which action should the nurse take?
- A. Ask the child if she'd like to wear a hat.
- B. Reassure the child that her hair will grow back.
- C. Explain to the child's parents that her reaction is normal.
- D. Suggest that the parents buy the child a wig as a surprise.
Correct Answer: A
Rationale: Offering a hat empowers the child to cope with her appearance change, addressing her distress directly.
After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the father states which of the following?
- A. There is no rectal opening for stool to pass.
- B. There is a tube between the trachea and esophagus.
- C. The nerves at the end of the large colon are missing.
- D. The muscle below the stomach is too tight.
Correct Answer: C
Rationale: Hirschsprung's disease is characterized by absent nerve cells in the distal colon.
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should:
- A. Give 15 mL of juice and give another 15mL in 15 minutes.
- B. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes.
- C. Give 15 g of carbohydrate and 15 g of protein.
- D. Give 15 oz of juice and retest in 15 minutes.
Correct Answer: B
Rationale: The 15-15 rule involves giving 15 g of fast-acting carbohydrate (e.g., 4 oz juice) and retesting after 15 minutes to correct hypoglycemia. Protein is not immediate, and incorrect volumes (15 mL or 15 oz) are ineffective.