Nokea
When developing the discharge teaching plan for a child with chronic renal failure and the family, the nurse should emphasize restriction of which of the following nutrients?
- A. Ascorbic acid.
- B. Calcium.
- C. Magnesium.
- D. Phosphorus.
Correct Answer: D
Rationale: Phosphorus restriction is important.
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A toddler is scheduled to have tympanostomy tubes inserted. When approaching the toddler for the first time, which of the following should the nurse do?
- A. Talk to the mother first so that the toddler can get used to the new person.
- B. Hold the toddler so that the toddler becomes more comfortable.
- C. Walk over and pick the toddler up right away so that the mother can relax.
- D. Pick up the toddler and take the child to the play area so that the mother can rest.
Correct Answer: A
Rationale: Talking to the mother first allows the toddler to observe the nurse from a safe distance, helping the child become accustomed to the new person without causing immediate distress. This approach respects the toddler's developmental need for gradual introduction to strangers.
To determine if a blood pressure reading is normal, the nurse must know which information about the child? Select all that apply.
- A. Age.
- B. Body mass index (BMI).
- C. A secret.
- D. Height.
- E. Occipital frontal circumference (OFC).
- F. Weight.
Correct Answer: A,D,F
Rationale: Age, height, and weight are key factors in determining normal blood pressure ranges.
An adolescent girl with a seizure disorder controlled with phenytoin (Dilantin) and carbamazepine (Tegretol) asks the nurse about getting married and having children. Which of the following responses by the nurse would be most appropriate?
- A. You probably shouldn't consider having children until your seizures are cured.'
- B. Your children won't necessarily have an increased risk of seizure disorder.'
- C. When you decide to have children, talk to the doctor about changing your medication.'
- D. Women with seizure disorders commonly have a difficult time conceiving.'
Correct Answer: C
Rationale: Consulting a doctor about medication adjustments before pregnancy ensures safety for mother and fetus, addressing teratogenic risks.
A 9-year-old child with Guillain-Barré syndrome requires mechanical ventilation. Which action should the nurse take?
- A. Maintain the child in a supine position to prevent unnecessary nerve stimulation.
- B. Transfer the child to a bedside chair three times a day to prevent postural hypotension.
- C. Engage the child in vigorous passive range-of-motion exercises to prevent loss of muscle function.
- D. Turn the child slowly and gently from side to side to prevent respiratory complications.
Correct Answer: D
Rationale: Turning the child gently prevents respiratory complications like atelectasis while minimizing discomfort in Guillain-Barré syndrome.
The nurse is assessing a child with celiac disease. Which symptom should the nurse expect?
- A. Constipation.
- B. Abdominal distension.
- C. Fever.
- D. Joint pain.
Correct Answer: B
Rationale: Abdominal distension is a common symptom of celiac disease due to malabsorption and gas. Diarrhea is more typical than constipation, and fever or joint pain are less specific.